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SANJOAQUIN 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 REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # ® ® V;7 Project Contact & Telephone <br /> � Facility Name C , Phone #&d ya3 ' <br /> L Address 4r9 99 &1v " 1` 6L 6? &J RPs ZX40/ Coot 9sS32 <br /> TCross Street <br /> Y Owner/Operato AZA)C <br /> o Contractor Name �,� �� ' �� Phone # 31r � 7 64 <br /> T Contractor Address , CA Lic ass# Cl <br /> �/D /f 1 <br /> AInsurerAVO Work Comp # �f- <br /> TICC Technician' s Name �,- �� y-p �/ Expiration Date <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) Installed <br /> T 1I / GT d `` L <br /> N ��� s� /'nl��® f GL S <br /> K <br /> P ❑ Approved IN Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name �� Date 3 _ 2 (i �� <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 /> Applicant's Signature ®7Z Title S� ® W�/ Date 42Z � <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"PAZ <br /> date below. <br /> and <br /> NAME R Zl fi' .4) T/td�TO�/ TITLE ""R�' S PHONE # % ' �`� � 7 �� <br /> ADDRESS Zfd • 6941 36 D6'33 s-n l &P/ r10>1w , <br /> SIGNATURE DATE /Z � 1,51 <br /> C L 6M9 �Ll ` l 2 of 6 <br />