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SAN`"J O A Q U I N Environmental Health Department <br /> ©U NTY <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 STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone L� <br /> Facility Name <br /> L �- Phone# .. Z..2BqV <br /> 1 Address M271 S P MMV- <br /> I Cross Street <br /> T <br /> Y Owner/Operator S Phone# Zp� E)ps- <br /> C Contractor Name ` Phone# "'��5 6152-2- <br /> O <br /> N Contractor Address 322L� 0R0dQAfj.WCA Lic# 31Z Class $ 0 <br /> T <br /> R A Insurer Work Comp# <br /> T <br /> ICC Technician's Name Expiration Date <br /> Q <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.97 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T —- -- — <br /> A <br /> N <br /> K -_-- --- <br /> P Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name �2 -- Date L7��C/2-W, <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 ISSUE[,I.SH Ir4 E-MPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature _ Tit1e t Date <br /> 2 2 <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 /> ackn3700!= <br /> ature andyiat��low. <br /> TITLE g�ii�(�*1/Q/ PHONE# <br /> ADDRESS o f 1 1 Vil X ► 01A C�rot`V2— <br /> SIGNATURE Ad� DATE <br /> 3of6 <br />