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SA N SJOAQUIN 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 START/EVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact &Telephone #/6"' <br />C <br />Facility Name rr 11/ptl Aroo4ccsj— <br />Phone# <br />I <br />Address p <br />TCross <br />Street <br />Y <br />Owner/Operator G� L r o ff rr C, �s Co <br />Phone # <br />C <br />Contractor Name 4 rA <br />Phone # <br />N <br />T <br />Contractor Address <br />Cri i N v L , �, jcf <br />CA Lic # �D/.� 3 4/_5-' Class <br />RInsurer <br />A <br />I J <br />Work Come# lOAc7B�l�6/p�... <br />C <br />T <br />ICC Technician's Name /� y ,�,'�yrnr�s�►,s <br />Expiration Date <br />QICC <br />R <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) <br />Tank Size <br />Chemicals Stored Current) y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved ❑ Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditi&s) <br />A <br />N <br />Plan Reviewers Name Date <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 H)RING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <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 />acknowledge <br />^ z -this responsibility for the billing by signature and date below. l C <br />NAME ei,"rf / `%r-Z� X TITLE fGfLLPH<, LGN PHONE # !�� �J7 ��7151 <br />ADDRESS J �4G I ���iL��,�J �� •3� <br />SIGNATURE <br />2 of 6 <br />y- / <br />ea <br />