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SAN JOAQUIN Environmental Health Department <br /> — COUNTY ..._ 64 <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 REPAIRIRETROFIT D UDC REPAIRIRETROFIT 0 COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # A^ QZ <br /> G Facility Name ,Mu �Oi Phone # '7p '] bq L} <br /> L Address 2!, Aj 'L <br /> TGross Street <br /> Y Ownar/Operators D ? u�p� Phone # <br /> oContractor Name b It L Phone # 7 S 7a <br /> N Contractor Address Z'L Ckeo✓t xtttost CA Lic # 5t7, $�( Class L e Z <br /> T <br /> A Insurer COC Work Comp # 4 3zlq - zli <br /> T ICC Technician' s Name Expiration Date z 'j <br /> R ICC Installer's Name �, Expiration Date �Zjhq <br /> Tank system work area Tank Size Chemicals Stored Currently Date AT <br /> (.e. 97 piping sump, 91 teak detector, UDC 12, eta) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name �. Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENTS 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:' I <br /> Applloant's Signature Title <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 ILL <br /> _ ��for the billing by signature and date below. ) ,707 <br /> NAME " u'1 LL TITLE 0t" L eft PHONE # 454 "IG Y7`7�y <br /> ADDRESS LZt ' ak l� <br /> SIGNATURE DATE Z <br /> 2 of 6 <br />