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� v�-6 5qc <br /> S ,J O h Q U I N Environmental Health Department <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 189 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIRIRETROFIT XUDC REPAIR[RETROFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site# r 0 0� �7 iQ Project Contact Telephone# 1� �$q ` <br /> A <br /> C Facility Name O a Phone# <br /> � Address W&- 72>-PK—V, CA 9557 <br /> Cross Street <br /> Y Owner/Operator f;�D� KND Phone# <br /> c Contractor Name Phone#77p_11 — 'g <br /> 0 <br /> N <br /> T Contractor Address -Pa Ax 3q f�A vlSb CA Lic# 11 S Class 4 <br /> R Work Comp Insurer ico.-S # dN1C�7AZ.b ZO! <br /> y z� <br /> T ICC Technician's Name 6,ggR 11e[daS J nZ b$ Expiration Date y z o I ZOICI <br /> R ICC Installer's Name :Rej NVW& -W� 10,_1862_ Expiration Date �f?18 U19 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le.97 piping sump,91 leak detector,UDC 12,etc.) Installed <br /> TzArn� ,r�?�S Druz <br /> A <br /> N <br /> K <br /> p F, Approved Approved with conditions Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N 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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THF 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 PERFORMA E OF THE WOR OR 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 this responsibility for the billing by signature and date below. �/ Q <br /> NAME 'b�4RR1 m y4%LETL. TITLE �kW9C� PHONE# Y VP 89 '7-27-C42-i/a <br /> ADDRESS_ 5670 ST+4T �D C �t19 1 0 A 3 <br /> SIGNATURE C DATE <br /> RE D <br /> 2of6 <br /> JAh 9, 2018 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br />