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SANJOAQUIN 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 # %kt <br /> A Phone <br /> O Facility Name z A10 <br /> Address 431Vte'� D� `r�OCV'6t4 �- Je� � `� <br /> T Cross Street &Let t e <br /> Y Owner/Operator C ( ai � �( b � o Phone # � S� � a (IS B <br /> C Contractor Name (� ut,LQ Phone # `� (} y ( <br /> 0 <br /> TContractor Address r a (6t�Ck CA Lic # 313, F° Classt Act Lt®tRA <br /> om <br /> AWork Comp #Insurer tcJ-,e. � � ( 9 <br /> T ICC Technician ' s Name t _ Expiration Date <br /> RICC Installer's Name — Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> T <br /> A C, <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (S Att chment With Conditions ) <br /> A <br /> N Plan Reviewers Name qnAkk 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 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." (f <br /> Applicant's Signature `� ' V � " ` v" �4 ' Title JjLZ.L g, Q46tW Date <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 billing by signature <br /> ee9and date below. !\ <br /> NAME kW1 1H &41'�1 . 4"E qO TITLE l l ` LaU60 l Jll It+4 PHONE # � U <br /> ADDRESS `� U t l) 1L, Lk t.. AUNLk. <br /> SIGNATURE ° ILI DATE � CL ` f <br /> 2of6 <br />