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AN JO N Environmental Health Department <br /> COUNTY— <br /> APPLICATION <br /> OUNTY-----APPLICATION FOR UNDERGROUND STORAGE TANK - - <br /> RETROFIT OR PIPING REPAIR PERMIT ' <br /> THHIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br /> D TANK RETROFIT 0 PIPING REPAIRIRETROFIT 0 UDC REPAIRIRETROFIT D COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name N d M l[, Phone# 2_0 „2 S% j <br /> Address <br /> I Cross Street <br /> Y Owner/Operator Phone# <br /> o Contractor Name Phone# S G -Li A t7 <br /> Contractor Address-2,%,%-? N CA Lic# Class 14 � <br /> A Insurer 4466 n 1Nork Comp# Z--Z-G G-7 <br /> C ICC Technician's Name <br /> T Expiration Date <br /> o ICC Installers Name 4,(. <br /> R ' Sp y'h V,t1� p.Y-,� Expiration Date � tje t <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e.87 pipkV WMp.81 lemic detecW,UDC W,eir-) y Installed <br /> T A �s c <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> NPlan Reviewers Name �� l + Date i04 <br /> PPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> OAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 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 PERFORMANC_ F THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> F CALIFORNIA." <br /> �v t <br /> pplicants Signature ®®TM& �"` � � pate <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 TITLE L� S�/V�Gr$ PHONE# <br /> ADDRESS g�-7 N 41-A-e— ?a", t� 'r'acc7i - <br /> SIGNATURE �� j <br /> S <br /> 2of6 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT ' <br />