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DocuSign Envelope ID : 3F72CA8A-4B4F-4888- BF4C-4E5763730B83 <br /> S A N1 O A Q U I N Environmental Health Department <br /> --- C O U N T Y------- <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERM !T TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ICCOLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # .nM 1 d c ^ c� L 9 % ; - 3 �5 <br /> A Facility Name Phone # <br /> I Address n <br /> L /5 :3 d, N /� r`94JWy , <br /> TCross Street (,�f c� •�z� `c x� />"Sd. <br /> Y Owner/Operator / 1 ; C14q e/l Phone # C510 J,`%G ;17V y <br /> C Contractor Name ^I 1 .II '' Phone # G U - ©6cjv <br /> 0 /l nr�riu.n r/ jr ryi el �j�ry;�j I � � l..�C <br /> T Contractor Address �q�7 A� J f Pig : n • ��/i CA Lic # IS '7 / 33 Class / 14z j <br /> R ) � / <br /> A Insurer 4r� N� lr j •j�UCJ i% # � fi .5 % Work Comp # % G1s� �O �. y Y �, <br /> C ICC Technician's Name `r; W44 /I L Expiration Date <br /> Q <br /> R ICC Installer's Name T Expiration Date t l <br /> ^� / 'Fc rt`t e Z p d � Oi� f7� 1 <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 (JS l �.�, �. l t t rig � . �c•�S PlI/ 00F 060 �c r' �i �J�/ ! oy. 1 Sll y v7 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions El Disapproved <br /> L ee ttachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date 10%b2 <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 , 1 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." l S <br /> � <br /> Applicant's Signature `i/yi � Title �? ' 'e� t 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 5ccrl l/d t� 1y cil TITLE j"u/ '�� PHONE # ) 261*v*>,3 ,1�S3 <br /> ADDRESS 30 0 cele-t'eL 14ye� J 1ij lej C � -JVan G � 0 lJ I <br /> SIGNATURE C ' DATE f 4v3 <br /> 2of6 <br />