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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 REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # /0- (Z to -off3—�v3[Z <br /> A <br /> C Facility Name SAK Phone# Z pq .qs - 016 <br /> I Address 44, <br /> L S't t0 7dn C ��Zb�o <br /> TCross Street <br /> Y Owner/Operator p Phone # <br /> C Contractor Name Phone # 9 6 �q 3. yf Z, <br /> TContractor Address CA Lic# dIo (o Class <br /> R Insurer <br /> A Work Comp # <br /> T [CC Technician's Name �`A4.x evie gov,,,. Expiration Date <br /> D ICC Installer's Name "�� <br /> R 3r+Ot,1h- 1-GW-WI a, Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detecto(, UDC 1/2.etc.) Installed <br /> T A,GL 3 d!-r!V <br /> b`S <br /> A <br /> N <br /> K eS <br /> P XApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A / _ <br /> N Plan Reviewers Name �ttty\ /5y o Date �/251� <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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 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 O THE WORK FO WHIC HIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO RKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." I 6 <br /> Applicant's Signature Title / L Date AS <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 signatures and date below. �j, <br /> NAME {fig ✓T J —A`rv'Q� TITLE I ro) CC4 (�,7d/4�`46 1�H E# i/ <br /> ADDRESS_ Y 61 WA-I'L{/IOUs-? <br /> SIGNATURE DATE % 4 <br /> 3of6 <br />