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nJ n (� ( I Environmental Health Department <br /> _ H. <br /> COUNTY <br /> APPLICATIONFOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 0 TANK RETROFIT 0 PIPING REPAIRIRETROFIT 0 UDC REPAIR/RETROFIT 0 COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # $ L( 7 <br /> G Facility Name ( f n c !3 L( (J Phone # <br /> AddressCf W r, a <br /> TCross Street 1 <br /> Y Owner/Operator (,td b fa✓► or �o Phone # <br /> i <br /> oContractor Name a Phone # C G cjG gb j <br /> T Contractor Address 45y IL <br /> S CA Lic # 966 3 q 5 Class /� <br /> AInsurer t3ee f Work Comp # <br /> T ICC Technician 's Name It t � Expiration Date jj � ( Z 421 <br /> R ICC Installer's Name Expiration Date Q Z l a2� l ZOZ ( <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (I.e. 87 piping sump, 81 leak deledor, UDC 1/2, etc.) Installed <br /> T 62 So o4 <br /> A <br /> N <br /> K <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> La ttachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date �� �202D <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, 1 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: "1 CERTIFY f <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 -�"� <br /> t / (f~ Title � Date 6 r f Z f 24> 2 P <br /> I I <br /> BILLING INFORMATION : I <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> i tank. If the party designated below Is different than the permit applicant, e.g. properly owner, the party must <br /> acknowledge this� responsibility for the billing by signature and date below. f ! 2 (� -7 <br /> NAME AytdGn �N'ry K TITLE f*r t ^ I Gr' PHONE # ` q t G ) � t/ t ~ � � l ( I <br /> ,bac , <br /> ADDRESS p� <br /> SIGNATURE DATE V ! lL <br /> I <br /> 2of6 <br /> 3 <br /> i <br /> i <br />