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SA N JOAQUIN 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 # j�. (,,.e� � "t rL. Pi <br /> C Facility Name S c' (L ` ) Phone # 6�' � hl ( � (� ( � g <br /> � Address `s S` LI. Ctd�/ LQ DC �ftr SoLO 14 <br /> IV <br /> Cross Street <br /> Y Owner/Operator Phone # LA � <br /> C Contractor Name S Old SU ( 51� , Phone # A40 <br /> 0 <br /> N Contractor Address �Cj Std � p5r� CA Lic # l 'd �{ Class �(�( �{(� <br /> T <br /> R Insurer Work Comp # <br /> A <br /> T ICC Technician ' s Name �. Expiration Date <br /> R ICC 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 1 /2, etc,) Installed <br /> T <br /> A <br /> N V <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L SXt chh �ment With Conditions ) <br /> N Plan Reviewers Name .C/�- Date 01 <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." <br /> e1xcu `hk -F& <br /> Applicant'sSignaturTitle " 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 and date below. <br /> NAME TITLE PHONE # <br /> ADDRESS <br /> SIGNATURE DATE <br /> 2of6 <br />