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SAN 'JOAQUIN <br />---- COUNTY - <br />Environmental Health Department <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 WIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone IF <br />LjorcL v k X�"c c '�i <br />A <br />C <br />Facility Name �� ,,, d /d i V, s )An C- _ <br />Phone # zp <br />1 <br />L <br />Address � Z' S I c -a h, Aq v <br />I <br />Cross Street p� <br />T <br />Y <br />Owner/Operator s` 6 I `r � � <br />Phone # Z c i <br />C <br />Contractor Name Gaon A C'Mo f� LM Se /b cAC 31.E . <br />Phone # 62 7 � X170 - )802 <br />t, <br />T <br />Contractor Address 3 6 1 ci i v\ , <br />CA Lic # <br />/ Q()$1/ �/ �� Class A <br />R <br />Insurer r�'� �m ?B�rSQ�+�.. i A �.r rw ,�� <br />Work Comp # 6t Z 1 `( 5`d'" rz J <br />T <br />ICC Technician's Name 'v z <br />Expiration Date Gr-/ - ZO2.? <br />a e .SGtMCIle <br />R <br />ICC Installer's Name Ax CL �G L S�Ctn�tG k C 2 <br />Expiration Date j - 4(^ ZO Z3 <br />Tank system work area <br />Tank Size <br />Chemicals <br />Stored Currently <br />Date UST <br />(Le, 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />Z Ci ��1' Sinn <br />G� <br />/ 6 Y�, <br />�'] ) <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions <br />❑ Disapproved <br />L <br />e Attachment With Conditions) <br />Plan Reviewers Name DateTT <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 <br />CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE <br />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, 1 SHALL EMPLOY PERSONS <br />SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA' <br />•Z <br />Applicant's <br />Signator /<f<< ✓f u Tille (,Q" a L`!� <br />Date 7 z0 Z <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 />aC knowledge ihis responsibility for the billing by signature and date below. <br />/�v 0 e-✓ r,, i TITLE <br />NAME ICL✓�t 61ti� IG' f� I ���n c,/L��Y! ff PHONE #��� 7 / �0 OP2 <br />7� C* <br />SIGNA <br />/-� <br />20(6 <br />Y�3 <br />