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S A N n10 A Q U I N 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 REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # I Project Contact & Telephone # <br /> � Facility NamePhone # <br /> L Address 2-�' ` 7 �'J arc%kenj L111c ' <br /> I Cross Street <br /> T _..... <br /> Y Owner/Operator ' Phone # ,Z,G0 <br /> _ _ r�rlUa��. �r� _ _ <br /> Contractor Name Phone # <br /> C M _ <br /> N y <br /> T _11 . -1 �- - -- ° 1 � � •� L 1 � # � � �-- ^`'�� Class <br /> Contractor Address CA Llc <br /> R Insurer i I /'S t� . , ��� 1G � > Work Comp <br /> T ICC Technician's Name 36)gyj �� r� � .� I Expiration Date "p . , ILL <br /> R ICC Installer' s Name I Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> 0.e. 87 piping sump, 81 leak detector, UDC 1126 etc.) Installed <br /> T — <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ( e A achment 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 /> 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." 7e.)CYy % �- <br /> Applicant's Signatur�Mt�'�V''4 V k�..�,G�J.it/l�• Tltle.��� � � �n� _��� I Date 16 'f <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 TITLE PHONE # <br /> ADDRESS <br /> SIGNATURE. A k: 1y � k DATE hq <br /> 2of6 <br />