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SAKAMIN <br /> Environmental Health Department <br /> -__ . C O l J N `Iv Y - .- <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 /> 0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Megan Mitchell 209-461 -6337 <br /> A <br /> C Facility Name sinclairPhone # 209_225_8513 <br /> I <br /> L Address 1001 F Yosemite Ave Mantpra Ca .95336 <br /> I Cross Street <br /> T <br /> Y Owner/Operator VenUS Phone # 2og_ <br /> o Contractor Name E to tr Contractors Phone # _ 43337 <br /> T Contractor Addressgwam O 2 CA Lic # 1001331 Class A - HAZ <br /> A Insurer Midwest Employers CasualtyCompany work comp # <br /> C <br /> T ICC Technician's Name Expiration Date <br /> R <br /> ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le, 87 piping sump, 91 leak detector, UDC 1/21 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 1 <br /> N Pian Reviewers Name ® r 'i Date Q 1 <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 FO THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." / r <br /> Applicant's Signature A. Title Qffire AggiSfignt Date <br /> BILLING INFORMATION : <br /> Indicate the resp nible 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 Megan Mitchell TITLE OfficpAt;gistant PHONE # 209-461 -6337 <br /> ADDRESS <br /> SIGNATURE DATE <br /> 2of6 <br />