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S A RJ O A Q U ( Environmental Health DepaNment <br /> - CC. 0 LJ 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 PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site # ( Project Contact & Telephone # <br /> C Facility Name Aja, , ( 7d ci Phone # 7, <br /> L Address qW 2 CJt�r1 ky__ - _C lu rJ �i '{WJE �rv. <br /> TCross Street Ti _ <br /> Y Owner/Operator �,� a,� �.,� Phone # <br /> o Contractor Name 6le VU : Phone # 70 7 SGq 5174 <br /> T Contractor Address �, V~ �;.,,.,u a� ; CA Llc # L 0 R Class 'S4&y <br /> R Insurer zm d Work Comp # 90ra 3 3 C <br /> C ICC Technician's Name Expiration Data AS <br /> R ICC Installer's Name- 111 Expiration Date ?Z46 W <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Isc B7 plpIrV sump, 91 Ink ftoolw, UDC 1/1, m�.) Installed <br /> T _ _ - _ _ 7 aSs 1 , wc. <br /> A a kr <br /> K L q k w tS� <br /> I <br /> P ❑ Approved XA <br /> pproved with conditions ❑ Disapproved <br /> L chment With Conditions) <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 /> OAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> EE 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 /> RKER'S COMPENSATION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 01 CERTIFY <br /> T IN THE PERFORMANCE ' F THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br /> •OF CALIFORNIA" � <br /> AN IIcml . sinouure sur f Title rLie P(> w L� Z S I <br /> BILLING INFORMATION . <br /> Indicate the responsible party to be billed for additlonal 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 th' responsibility for the billing by signature and date below. 1 - ,�, �J 7 /� <br /> NAM ol <br /> TITLE V� �,IL , dam' + PHONE # 701 S A / ! ` 1 <br /> ADDRESS 22�t 1 �Y /" t ? 'X_ <br /> SIGNATURL •'tDATE <br /> Z of 8 <br />