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DocuSign Envelope ID: 3F722CA8A-4B4F-4888-BF4C-4E5763730B83 <br /> SAN =I 'J O A Q U IN Environmental Health Department <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> MAR t 1 . 2024 RETROFIT OR PIPING REPAIR PERMIT <br /> ENVTHIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> I'IEl4 NIKUMIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # �wM C; 1. �� `�j 9 %7 . 3 e3 <br /> A <br /> C Facility Name (jJJJS . _ stimoc.� 7{ v"t Phone # (,yjv a�l( - Ajpy <br /> I <br /> L Address j d <br /> �5 .3 N LS rD4d Ury <br /> T <br /> Cross Street wa tz� �oc h' 1 <br /> Y Owner/Operator /V ; &4 (i e// 60 /7e/ Phone # (510) d,`/G <br /> G Contractor Name ,I / <br /> o /� rhGr; ehn n k rv;kl 8jrwexs /` Phone # wet vol - 6do o <br /> T Contractor Address 1717 4& v J 2d A0464 , ,4 v <• CA Lic # ,7,S•7133 Class <br /> A Insurer 6,140,% <br /> .1V/4lC .1'r j •jilo #' 3 ) 51g Work Comp # <br /> T s ICC Technician' Name -� <br /> T / y •n /11cr •��� Expiration Date <br /> ICC Installers Name �n <br /> Ro ' 7r-s•, / 'iu- �t� c.'L Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 pi//ping sump, 81 leak detector, UDC/112, etc.) p Installed <br /> �s / C��M <br /> .r ' <br /> �. ldA w 4 l ;�ds PL t 0, 4)00 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L Be ttachment With Conditions) <br /> A <br /> N Plan Reviewers Name r� - Date /VLO/2 2L <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," r y <br /> Applicant's Signature !sVPP�Z Title Y'?y'�e� 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. l �j r <br /> NAME Scrn, Vey/ 6 Gly �i�1 TITLE �yh1 �' PHONE # �i ( / �" C/,3 �J <br /> ADDRESS 3cko [ 01 " eprGL Xy& C �J in .e. G4 <br /> SIGNATURE DATE // A3 ch l�1 <br /> 2of6 <br />