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SAN'J O A O U IN E•nvironrnental Health Department <br />----C0UNTY-- <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 />EPA Site # Project Contact & Telephone # �� �'� 41,!r 71 01 <br />A <br />C <br />J� / <br />Facility Name r. �iyoh Ape -4c,7-5 c' _s Phone # <br />I <br />Address 1 ' 11 � Yr <br />TCross <br />Street <br />Y <br />Owner/OperatorPhone <br /># <br />o <br />Contractor Name �y� /t7� �,, �n f -r; Phone # <br />T <br />Contractor Address �j �� �,� �� r J, �, �� CA Llc # Df) J ,:/s Class ,Q Cf G 2)- <br />R <br />Insurer -- L� 'T ic. i.S �r�'1 n <br />Work Comp# <br />T <br />ECC Technician's Name �, �t S� IrhH`r,S <br />Expiration Date <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />(I.e. 87 piping sump, 91 leakdetector, UDC W, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />A <br />— <br />N <br />-- <br />K <br />❑ Approved V Approved with conditions ❑ Disapproved <br />P <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />%� c� G <br />Plan Reviewers Name 1 \ Li 44 2n 1-� /1�V date rel ail �!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, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA".) <br />Applicant's Slgnalure Title!/�_Yi� r Cj 1/ 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 />acknowledges tthis responsibility for the billing by signature and date below. / 91"!r' <br />NAME er�c- �� H / r L Vr�y TITLE f u7� L.! a /t> 011 PHONE # % 1'� ���r ✓ / / �� <br />ADDRESS J,-, J Ci l d . L. -�l <br />SIGNA <br />2 of 6 <br />TE Z' %7" 1)6 <br />ej `L <br />