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SAN, JOAQUIN Environmental Health Department <br /> COUNTY <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# - <br /> C Facility NameMA. Phone# - 602 -Fjgt2 <br /> Address -,!2 LMnc _ 1 _ 0 <br /> I Cross Street <br /> Y Owner/Operator Q h Phone# <br /> oContractor Name Phone# <br /> N + <br /> T Contractor Address _ CA Lic# �� Class CAu <br /> AInsurer 1 Work Comp# <br /> T ICC Technician's Name Expiration Date <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> p.e,87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T <br /> A <br /> N <br /> P with conditions ❑ Disapproved <br /> L (See (Approved <br /> chment With Conditions) <br /> A <br /> N Plan Reviewers Name Date- Z 20 <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 AGENTS 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 T IE WORK FOR WHIC. THIS PER S ISSUED,K EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA. <br /> " <br /> Applicant's Signature Title �_ _ { 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 /> acknowleddgge�this respo�n/s}iibiiilli for th�e'}billing by si ture a d de g , r 2 <br /> NAME ..ter r& A I�1�1 TITLE �Y�,(V PHONE#LAUP) -A tot) C�� <br /> ADDRESS ��� l�Jt. r t` �, V 6V� ti �� C.J� r l <br /> SIGNATURE AJ/ _ DATE 2- ?i �2-02-!� <br /> 3of6 <br />