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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 REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE pp�� <br /> F EPA Site# Proiect Contact&Telephone# ��t ~t <br /> A <br /> Facility Name , r Phone#21Dq-. <br /> I Address 3 , l Iq r7 2. <br /> L <br /> TCross Street <br /> Y Owner/Operator L. aiIj. V Phone# <br /> c Contra( c' j Phone# <br /> T Contractor Address ) 921'_CA Lic# Cjc ��r(.� Class$ l 0 f f <br /> A Insurer "Ainc Work Comp# <br /> TICC Technician's Name G� Expiration Date <br /> R ICC Installer's Name �j�,e '{� � � Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e.87 piping sump,91 leak defector,UDC 1/2,etc.) y <br /> Installed <br /> T <br /> A <br /> N <br /> KIrk 0At <br /> P Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name � /bL /�i.�r4�� Date_ VI, Lc Zp <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- HE WORK FOR WHICH THIS PE MIT IS ISSUED I SHAL PLOY PE NS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." // 1 ►y� ` <br /> Applicant's Signature <br /> Title 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 /> acknFlipcige this r sponslbili for thyellbiplli/n�g by si ature nd at I t {� <br /> NAM ' 1C L�,� 1 TITLE V PHONE# LADe)—2A,3 o0al <br /> ADDRESS <br /> I l J� � <br /> SIGNATURE i DATE <br /> 3 of 6 <br />