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Environmental Health Department <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 REPAIRIRETROFIT 0 COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # U41r it5M �k Mn 4(v4- jj <br />A <br />C <br />Facility Name <br />Phone+# <br />L <br />Address �1 <br />Cross Street <br />Y <br />Owner/Operator C � � <br />Phone # �'- r3� - 71 io�l'Z <br />� <br />c <br />Contractor Name �� °��/ = <br />it= � c(�) <br />Phone # [ �0 � — ( <br />till =7 <br />O <br />i . <br />T <br />Contractor Address l inn �, ` ;� (112CA <br />Lic # • lea Class <br />R <br />Insurer' . - <br />Work Camp # <br />A <br />,. <br />ICC Technician's Name 4 1 <br />Expiration Date <br />o <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(I.e. 87 piping sump, 91 leak detector, UDC 1/2 etc.) <br />Installed <br />T <br />A <br />N <br />} <br />iK <br />144 <br />P <br />❑ Approved ,Approved with <br />conditions ❑ Disapproved <br />L <br />(See Attachment With <br />Conditions) <br />A <br />N <br />A �Q�iIOJ\l <br />Date <br />Plan Reviewers Name. t U rv� <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 <br />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:' NTRACTOR'S HIRING OR SUBCONTRACTING <br />SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT <br />IN THE PE FORMAN OF/THE WORK FOR WHICH THIS PERMITISIS�IS..S�UyED, S A <br />EMP40_Y P "RSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA."� �1 <br />Applicant's <br />SignatulU Title C'C <br />� � 4 Date ' L <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 />acknowleddgethissrre-ssponsibilit'y four t'he billing by si nature and dat ,p@low. <br />NAMdk VV `6 M t � TITLE (2 � `��IR Ute' PHONE # `���� <br />Ar�nRESS �YJ "� ► `� 1 1 Y Cft <br />l� ` L ( 1.^A <br />TE �� <br />"f <br />