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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 /> Facility Name N D Q`it�` (Slvs„ 'tom' ] 1D Phone # <br /> L Address G. l `'l w GIZ L.{ _ � � e C S31 <br /> TCross Street <br /> Y Owner/Operator v eU ( Nj S NQ�� Phone # — I <br /> C Contractor Name Fr'4 — C,(f; Clz, , ILA lhJC 1( WC Phone # ( S — ;m O — o <br /> 0 <br /> N Contractor Address FO jcft�DX CA Lic # S 'g � G71 Class Ar, <br /> T <br /> R <br /> A Insurer Work Comp # <br /> C <br /> T ICC Technician 's Name N \ �C. 00 ✓ Expiration Date Iq 23 <br /> R ICC Installer's Name I2.z,< / Expiration Date 6 2q 23 <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 <br /> K <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <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 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." V. _ _ / <br /> Applicant's Signature Tide � �'� S' � �'��� Date O�/ (A> / ��� <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 <br /> this responsibility for the billing by signature and date below. <br /> NAME N � f`-- �/ ' ` I� TITLE "'� PHONE # J _� <br /> ADDRESS <br /> SIGNATURE/ DATE <br /> 2of6 <br />