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SANJ O n Q I �I N Environmental Health Department �p <br /> __.....__.00UNTYu.... .__... !f` l _HWED <br /> APPLICATION FOR UNDERGROUND STORAGE TANK OCT 0 2 2017 <br /> RETROFIT OR PIPING REPAIR PERMIT 8MffiW0ffALHMLffi <br /> pewwmm <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 /> 9 on <br /> F EPA Site# Project Contact&Telephone#�/� S �► <br /> A <br /> D Facility Name �S Q,•S; k,eL _3Z Phone# <br /> IAddress ! — v`p jl t �� �S�3 <br /> I Cross Street <br /> T <br /> Y Owner/Operator �d �v cyl�f Phone# <br /> o Contractor Name ✓�`c .76 <br /> Phone# �j/yG �� <br /> N Contractor Address ` �'' 'ou- c� �� J, ?'7 Z <br /> T CA Lic# Class <br /> AInsurer </�4 G Work Comp# b <br /> TICC Technician's Name _ Expiration Date 91 <br /> RICC Installer's Name Expiration Date Z 19 <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 (See Attachment With Conditions) <br /> A ` <br /> N Plan Reviewers Name Com" Date �l/KA/ e:_ ` (7 <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 ERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signatu Title V �_C1 Date 2� J <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 nesponsl lity for the billing by signature canted dates below. <br /> 17 <br /> NAME ` K � TITLE v ��v� Ce PHONE# sy- SZ� <br /> ADDRESS `-' 3 / A) �417 <br /> �C <br /> S � <br /> SIGNATURE DA <br /> / / 2 <br /> 2 of 6 <br />