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SA N J O A Q U i N 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 />EPA Site # <br />Project Contact & Telephone # �� `j tf �. 71 el <br />A <br />O <br />Facility Name 64 C� $i f10,0 Ae0W G S <br />Phone # <br />I <br />Address <br />1 <br />Cross Street <br />T <br />Y <br />_ <br />Owner/Operator G z r' o ff vz+ u f S �'� <br />Phone # <br />oContractor <br />Name �� <br />Phone # <br />TContractor <br />Address �,, v i , c.Ib <br />ow -erJ <br />CA Lic # �QQ 3 t�� Class 4,17 <br />R <br />A <br />Insurer �' <br />%yr o hS A h ,wr <br />Work Com # <br />p /OOc7CO/Cf 6/ t— <br />cICC <br />T <br />Technicians Name <br />'/'�- y ,Si ��s <br />Ex Date <br />Expiration 17-/� <br />RICC <br />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 />K <br />P <br />1 <br />El Approved ! Approved with, conditions ❑ Disapproved <br />L <br />(See Attachment With t\ditions) <br />A <br />11 <br />N <br />Plan Reviewers Name "1 A Date �da-71 <br />WS, AND RULES AND REGULATIONS OF SAN <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINAN\RE <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANUCH A MANNER ASTO BECOME SUBJECTTO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOYBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signature Title <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payme t coverage per <br />tank. If the party designated below is different than the permit applicant, e.g. property owner, th party must <br />acknowledge this responsibilityforthe billing by signature and date below. r r <br />NAME [rG s� H rt / ` l���(/L�TITLE L/L L +;+! /r— G1 PHONE # ! �� �� `� 7/ <br />ADDRESS s(aL , J �++ ��, :J �4G I6 > CJ�iL��, �J-�?-3 <br />SIGNATURE <br />2 of 6 <br />2of6 <br />Z- "y- /Y- <br />Y- <br />47- <br />4Z <br />