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SAN <br /> JOAQUIN <br /> O A Q I I I N Environmental Health Department <br /> +.7 O UN 1 <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 REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone <br /> C Facility Name Phone # <br /> Address `. �{'Z�j <br /> L f 01 Gj u'1 (c <br /> I Cross Street — J' <br /> T ---- — <br /> Y Owner/Operator ark. v) w W 46bl,) Phone # <br /> oContractor Name - S —r Phone # <br /> N T Contractor Address UE50 G��i CA Lic# 45fbta54 Class g0A,,,1ID40 II <br /> AInsurer SG� �� a1 Work Comp # <br /> T ICC Technician's Name Expiration Date <br /> RICC Installer's Name L Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump,91 leak detector, UDC 112, 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 /> IN PlanReviewers Name'V[�lllDZ�Q tZ Date_l0 ` " /Z <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 PE IT IS ISSUED,�1 SHALL WLOY PERS NS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." Al trY1 � g'trtj <br /> Applicant's Signature j Title C�C�' 2 � �{t )Y 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 sigRiure and dale beelloowr c <br /> NAMEP,Wi-5�YZCi� 1-?.'t�l/� TITLE C�PXX"'TC�� Y-P> PHONE# <br /> ADDRESS �V `2 <br /> SIGNATURE DATE kL3 l�2 Sr <br /> 3of6 <br />