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SANJ O A Q U I N Environmental Health Department <br /> --COU NHTY--- <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# /4i� �-3 / <br /> Facility Name G' L N� �� - Phone# <br /> IAddress f Z 3 A <br /> I Cross Street <br /> T _ <br /> Y Owner/Operator C lir' vnA C,1-3 60 Phone# <br /> 0 Contractor Name Phone# Ab/' lc�le' .� <br /> N Contractor Address 3 .� CA Lic# 300.;4 , Class Q <br /> Tq/h L�fi .3 Gd►� ✓ <br /> AInsurer /6t�►L ,i/ 2yh ti w� �i,c. Work Comp# 100d 00 j-16'/OZ- <br /> TICC Technician's Name Q y w Expiration Date <br /> R <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 (See Attachment With Conditions) <br /> N -3ZPlan Reviewers Name tx Aim Date <br /> APPLICANT MUST PERFORM ALL WORK IN ICORDANCE WITH SAN JOAQ�IN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LL CENSED 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." <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. <br /> NAME —�L:Z/+m r,, TITLE � PHONE# 914'� <br /> ADDRESS w yvir, /W /�vv ✓ce �/� StiG;! c�A►�i,-� �✓`�� � <br /> SIGNATURE DATE <br /> C'111 <br /> 2of6 <br />