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SAN10 A Q U I NEnvironmental Health Department <br /> C_ 0U [\] RECEIVED <br /> APPLICATION FOR UNDERGROUND STORAGE TANK .IAN 0 5 2024 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> ENVIRONMENTAL HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE , INDICATE PERMIT TYPE BELmRMIT / SERVICES <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STTART/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # <br /> C Facility Name �lQ o CAM/?# <br /> � Address $ �' /�'� DGS i�Gf C_AM <br /> I Cross Street <br /> T <br /> Y Owner/Operator � � Cj ` ml Phone # <br /> oContractor Name1 'De� � Phone # 57-2 — C <br /> T Contractor Address C) i Fol JAI <br /> r \y; �� d �, y � CA Lic # IR r I f 7 Class �} �}!j2 Cie <br /> A Insurer 'alb✓�l1'1(,C lM 11 � \ t' 1 Y `� l.� "� Work Comp # �; 5I� — SC (N(p7'� <br /> T ICC Technician 's Name <br /> T JbIr (,kLLr tjILOL Expiration Date <br /> QICC Installer' s Name ` ^ <br /> R UV , � ULIYhA I /� Expiration Date I <br /> Tank system work area Tank Size Chemicals Stored Currently ate UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1 /2 , etc.) Installed <br /> T 64l .je \ b fix. RP ,401sr Q e <br /> N c, - - 3a <br /> K <br /> P ❑ Approved Lid Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N <br /> Plan Reviewers Name Date r , <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 Signat odw� Title 6 � Date <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 DATE <br /> 2of6 <br />