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SAN 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 # <br /> � <br /> Facility Name rj `� Phone # <br /> L Address <br /> I Cross Street ' — S` <br /> T <br /> Y Owner/Operator Phone # Qd g3riSid <br /> C Contractor Name µ0; 1L � Q_ E , Phone # <br /> 0 <br /> T Contractor Address a aa, 4 ( l4 CA Lic # � � a,% � Class � <br /> R Insurer Work Comp # <br /> A <br /> C <br /> T ICC Technician 's Name Zl2woq Expiration Date <br /> Q <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 /> K 6 <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L See Attachment With Conditions ) <br /> N Plan Reviewers Na 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 <br /> HIICH ,T.H,IS.-PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." r �1 � W Aller 514 � �-1 . <br /> Applicant's Signature L (r-t.f - 0 Title 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 NoLa V41I� 7 . UJ ` U,4L" l ITLE C�� �� Y PHONE # �� � C� ' <br /> ADDRESS . O b 6LoLu� J N ��-- <br /> SIGNATURE 141 DATE <br /> 2of6 <br />