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S AA I 0 A ' n U I N ' <br /> 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 AP ROYAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT DC REPAIR/RETROFIT ❑ COLD START/EVR PGRADE <br /> F EPA Site # 0&? 400o Project Contact & Telephone # �, AUQG Z j <br /> A qj <br /> C Facility Name Zt 6A" I e j L L" C, Phone # <br /> L Address CV50 <br /> T Cross Street or of <br /> "' <br /> Y Owner/Operator �" Phone # <br /> C Contractor Name AFFORDATEST Phone # <br /> o _ <br /> N <br /> T Contractor Address 416 2ND ST , GALT _ _ Class <br /> A Insurer Work Comp # <br /> TAMY <br /> ICC Technician's Name 4ZANE NIMMO <br /> T Expiration Date 5%26/2023 <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 07 piping sump, 91 leak detector. UDC 112, etc.) Installed <br /> T PLLD VEEDER ROOT PRESSURIZED LINE LEAK DETECTOR - 91 TANK <br /> A <br /> N <br /> K <br /> REG D <br /> . � <br /> P ❑ Approved Approved with conditions ENONNMENTT <br /> L (See Attachment With Conditions) HEAL C�y ANT <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 OR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> 2 Appllcant's Signature j Title Date -� t X23 <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 /> NAM771 <br /> E ULffT� E PHONE # <br /> Xq 0 <br /> ADDRESS rA <br /> SIGNATURE ��T DATE )Mel <br /> 2of6 <br />