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SAN-. J O A O U IN 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 # �� T^3 �� 7P <br />C <br />Facility Name r- pfeoti PI-OW44 r, s <br />Phone # <br />I <br />Address <br />TCross <br />Street <br />Y <br />Owner/Operator G� L y. �'� <br />Phone # <br />oContractor <br />Name H �„ �� <br />Phone # <br />T <br />Contractor Address �,� `, L , j� <br />CA Lic # 300 3 Z/," Class A ff C0 <br />RInsurer <br />A <br />L� To.hc tis J7%M ,•rr�� <br />Work Come# /®Oc�GOl4''6`/nZ <br />cICC <br />T <br />Technicians Name <br />'/'�y ,si+srnrnr',s <br />Expiration Date 6*- 17- <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 1/2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />ny <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 Conditions) <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 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 T 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 this responsibility for the billing by signature and date below. <br />NAME eZz- 1 + h / ` LL�t/L�_TITLE G!L L �r+� lz. G� PHONE # l �6" �J 4U l / 51 <br />ADDRESS �CJ l,7 Gs lA+ 44lz , ��-f ) lit, `7 <br />SIGNATU <br />2 of 6 <br />' rL,11�1. � _OF7,3y <br />TE Z.' / IG' <br />,Z <br />