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SA N J O A Q U IN Environmental Health Department f� <br /> — COUNTY— <br /> JAN 232018 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: � [ & MENT <br /> D TANK RETROFIT PIPING REPAIR/RETROFIT D UDC REPAIRIRETROFIT D COLD START/EVR � DE _ <br /> F EPA Site # Project Contact & Telephone # <br /> C Facility Name V Phone # <br /> IAddress yCA Ctc:J7 D toWd <br /> I Cross Street <br /> TPhone # �� • 3510 9�v <br /> Y Owner/Operator 6{ 1 e*� Sin4k, <br /> D Contractor Name 7171 <br /> Phone # 1 <br /> N �' CA Lic # ' Class C-U( R <br /> T Contractor Address <br /> R Work Comp # 921gq <br /> A Insurer a Cn e. <br /> T ICC Technician's Name S Expiration Date 10 <br /> o ICC Installer's Name Expiration Date ^ 1 - Z,O <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 12, etc.) Installed <br /> a <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> Ay <br /> N Plan Reviewers Name Ste[ � jF�JeAb0 Date 143 <br /> �� <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: 111 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: 9 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." t <br /> Applicant's.Signature 1 Title n4ghe Data " I <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 1billing by signature and date below. /] r <br /> S <br /> NAME.VJaM -.1f.o I1 CTITLE PHONE # SS( �Zq 1 � <br /> ADDRESS � OV/ ' Y J y -e V <br /> e <br /> SIGNATURE DATE <br /> 2ofe <br />