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SAN,,-JOAQUIN Environmental Health Department <br /> OUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 18D DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT 'COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone I C'• i y 13 4ka; <br /> C Facility Name ) T Phone# <br /> 6' <br /> � Address 2.05 <br /> TCross Street <br /> Y Owner/Operator Ql.h, K one# <br /> c Contractor Name Phone#4 > —'A I k-2-)L4 <br /> 0 <br /> T Contractor Address ��', ( CA Lic# 4( Class B Cla� � <br /> R Insurer Work Com #• <br /> T ►CC Technician's Name Expiration Date <br /> ICC Installer's Name 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 _ 1 <br /> N <br /> K <br /> P Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A I ZD <br /> N Plan Reviewers Name M Date t�( 1�` <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 ISSUED,1 HAL E OY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." �J��-��, p �i-A. <br /> Applicant's Signature � �`•---� 4 Title Data <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 signature and_ ate below. <br /> NAMED ( kb! a TITLE ` l� PHONE# Ube-ZA�!> CC03� <br /> ADDRESS { <br /> SIGNATURE ( i.. � �S � m - t DATE �l l! Z�7r <br /> 3 of 6 <br />