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Will <br /> SAN JOAQUIN <br /> OAQU ( N Environmental Health Department <br /> - - <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 EPA Site # Project Contact & Telephone # SutA S � 4'g' Z— Z <br /> A Facility Name Sh , � . Phone # g " Z � I ZVS- <br /> � <br /> Address C es cAj c vA CA 9S,�Zo <br /> TCross Street <br /> Y Owner/Operator S` � WA s� k Phone # W1 mt? Of 't " 12S's <br /> C Contractor Nameh/�, ri0,^ Phone # � 1.. •. 61 <br /> 0 <br /> T Contractor Address 1 2 40H Sebakshy A CA Lic # 9 SA 4 6 7 Class )q <br /> A Insurer p 6 r444% A rn exi G4 ✓1 Work Comp # 2to8 25� <br /> T ICC Technician 's Name 0 I 5 6 (� 'L � Expiration Date <br /> o <br /> R ICC Installer' s Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1 /2, etc. ) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved >< Approved with conditions ❑ Disapproved <br /> L ( ttachment With Conditions ) <br /> A <br /> N Plan Reviewers Name Date <br /> �� �� <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDA E 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." R �w v /yAApplicant's Signature AZAJ4 Title 0V~ 1 Q io <br /> r Date 211 !412w019 <br /> r � <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 this responsibility four the billing by signatures and date below. ' w �} r �+ <br /> NAME SA' Rw !% 4W 1V S11 TITLE n.s; � PHONE # 2Dq ^ 9g2 - I ZJ J <br /> ADDRESS I ex, CA32 <br /> SIGNATURE -+r DATE <br /> 2 of 6 <br />