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ENVIRONMENTAL HEALTH DEPARTMEN <br />SAN JOAQUIN <br />.00 East Main Street,• • • 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION UNDERGROUND STORAGE TANK <br />TETROFIT OR PIPING REPAIR PERMIT I <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 />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name '� <br />Phone # o <br />L <br />AddressLk o iPLQJ <br />T <br />Cross Street <br />Y <br />Owner/Operator 1, <br />Phone#2.,,,q <br />oContractor <br />Name <br />Phone # , <br />N <br />T <br />Contractor Address PO Bm (D 2 <br />A Lic # Class <br />RInsurer <br />A <br />Work Comp # <br />C <br />T <br />ICC Technician's Name <br />Expiration Date <br />Installer's Name <br />Expiration Date <br />oICC <br />R <br />Tank system work area Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />T <br />' l L. <br />�i <br />A <br />® 0 <br />491 <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 Q Date__ <br />ki <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 WOIRIVOR WYCH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />t <br />Applicant's Signatur Title Date <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for the billing by signature and date below. <br />ibil <br />NAME l -i1,T TITLE V PHONE # <br />ME <br />SIGNATURE / <br />EH230038 (revised 08/1/11) <br />2 <br />i <br />DATE I �� <br />