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SANJOAQUINEnvironmental Health Department <br /> COUNTY <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# 91AC k3 41,5r 7/T <br /> A <br /> O Facility Name C4 P-0/,I Phone# <br /> I Address ��3 .� <br /> L ��� a1� Adc, <br /> I Cross Street <br /> T <br /> Y Owner/Operator C y p y0 v o W24 G% 60, Phone# <br /> o Contractor Name �� e Phone# 91Z, <br /> T Contractor Address 3� ye liar, �' ,j CA Lic# 300.34, Class PC j) <br /> A Insurer �� ,"a� fa? w „H L ���. Work Comp# l Coo 00 I-IC 1 CZ_ <br /> T ICC Technician's Name ,' '"`� Expiration Date <br /> RICC 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 112,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 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 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 /> acknowledgethisresponsibility for the <br /> /billing by signature and date below. �a J, 3 <br /> NAME el,*_ e t� J��GCs ,`/ TITLE Aer'l' ,K±t /C,-C,4' PHONE# !14" 13 f1( 9 <br /> ADDRESS . ) 1a'+r, i`e /Svc ✓� elm .7 ��C,® [��Gi-P �� � � <br /> SIGNATURE DATE <br /> 2of6 <br />