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SAN JOAQUIN <br /> OAQU ( N Environmental Health Department <br /> COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # " cu W &4,i, 42m 4624 (14W <br /> (1 'W <br /> C Facility Name � , S u � Phone # a Q 41 <br /> Address ►� t (� (D � kbv {- jot LAC4A CAe C? sVa 1 b <br /> Cross Street , a.Uk L .e., <br /> T <br /> Y Owner/Operator :P -� Cit N Phone # ljq �' ` / c('Ff a <br /> oContractor Name (,� �� u (� �,� e, , Phone # <br /> N Contractor Address 4 �� ip � Q � ('7 CALic # t; 4t{ Class A �C( O 02 <br /> R Insurer Work Comp # <br /> A <br /> c ICC Technician 's Name Expiration Date <br /> T <br /> oICC Installer's Name Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (I.e, 87 piping sump, 91 leak detector, UDC 1/2, etc.) Installed <br /> T <br /> A e <br /> N tt ` <br /> K J V - Ole� <br /> l ' <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WO N ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES , STATE LAWS , AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING : "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature "ql_ v � e itle t C &4/"' 0% ]� <br /> Date I <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank . If the party designated below is different than the permit applicant, e. g . property owner, the party must <br /> acknowledge this responsibility for the <br /> billing by signature and date below, N � Q �j p <br /> NAME 1'� �rj (L( r " ` 'dt hkAk/ TITLE �` C1' PHONE # 0 '+ " N3-4 & Q <br /> ADDRESS �(' � d U � � � � <br /> SIGNATURE-A QA C ,4 DATE <br /> 2of6 <br />