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J A K-J V A Q U I N Environmental Health Department <br /> OU 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 START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name Phone# <br /> � Address 2 nIr 5 7�S <br /> TCross Street <br /> Y Owner/Operator _ Phone# EbS 2-11- _44b2- <br /> Q Contractor Name Me mail, Phone# <br /> 0 <br /> T Contractor Address 2_-L4 {%GU, L CA Lic# Class <br /> A Insurer 1 Work Comp# <br /> c ICC Technician's Name <br /> T Expiration Date <br /> o ICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Date UST <br /> (.e.87 piping sump,91 leak defector,UDC 1/2,etc.) Tank Size Chemicals Stored Currently <br /> Installed <br /> T — <br /> A <br /> N <br /> K <br /> P Approved with conditions ❑ Disapproved <br /> L (See A achment With Conditions) <br /> A <br /> N Plan Reviewers Name Date__ 2l1012 5 <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 PERFORMAN�E F THE WORK FOR WHICH THIS P.EZMIT IS ISSUE,D,II SHALL EMPLOY PRR ONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." ',�� �1`�., <br /> Applicant`s Signatu Title , Date a <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 responsibili_�for the billing by sig ture and date llo�w,. J <br /> NAME�i� LV14)M V �1 ' TITL _nOY'( PHONE# <br /> AVID <br /> Ale-, <br /> l Q 1 ` <br /> ADDRESS i 1 1 , 1V� � �t �j� _ 1,EQ 6 L Z <br /> SIGNATURE DATE <br /> 3of6 <br />