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SANJOAQUIN Environmental Health Department <br /> COUNTY - <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> , ((�� <br /> h RETROFIT OR PIPING REPAIR PERMIT <br /> 4 <br /> le�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 # R&v { <br /> � <br /> Facility Name ` /S� � 1 0 ��$ Phone # <br /> Address 14 � � `I ' 4 ovG� &Tc Lir"uL S4ocAt4a t C� Sll eL <br /> Cross Street <br /> T Phone # <br /> Y Owner/ erator �.�, • t�Et� 1/r(S l <br /> o Contractor Name Sc"Ck6b 71,kTo'l ' S{ usj TSL' , Phone # 40 X113 jpC�; $ <br /> N Contractor Address to ' b k0 t c.{ 1, L ALiccg CA Lic # CV Class <br /> T <br /> R Insurer Work Comp # <br /> A <br /> C ICC Technician 's Name <br /> T �� Expiration Date <br /> ICC Installer' s Name P <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le, 87 piping sump, 91 leak detector, UDC 1 /20 etc,) Installed <br /> T <br /> A <br /> K V <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ( Se)Attachment With Conditions) <br /> A ! J <br /> N Plan Reviewers Name / Date �� Z9 1 V, <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 /> en f wn `� '/ vctY > Title <br /> / n� IJ�M (: Date <br /> Applicant's Signature L a� C c <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 thisresponsibility for the billing by signature and date below, <br /> 4Q % y�/ <br /> R <br /> NAME kLthq, �l? al ct(Llq. A li TITLE `� 1�� 1(L�L l!1PHONE # <br /> ADDRESS QU, (Avil. S(} it fth <br /> SIGNATURE @Q Co�^ V ' `lx [� G� _DATE <br /> 2 of 6 <br />