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SAN 1 AQUIN <br /> Environmental Health Department <br /> --COUNTY— <br /> APPLICATION FOR UNDERGROUND STORAGE TANK - - <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> T'HiS PERMIT EXPIRES 180 DAYS FROM THE'APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 0 TANK RETROFIT 0 PIPING REPAIRIRETROFIT Q UDC REPAIRIRETROFIT 0 COLD START/EVR UPGRADE <br /> A F EPA Site# ,Project Contact&Telephone# <br /> C Facility Name i Phone# 2j�, g_ ? t <br /> L Address ZSR <br /> TCres Street <br /> Y Owner/Operator Phone# <br /> C <br /> Contractor Name y c_e Phone# ..�q <br /> �.. S " C-4i(I-j.. -7S 0 <br /> T Contractor Address 2CA LIC# '7 '? Class <br /> A Insurer ACe Amender d Work Comp# (r,(Q - <br /> cICC Technician's Name <br /> T Expiration Date <br /> OR ICC Installer's Name <br /> Expiration Date Z (� t <br /> Tank system work area Date UST <br /> (Le.87pVM swnp.91 leak deWeter,UDC 12,etc.) Tank Size Chemicals Stored Currently <br /> Installed <br /> 44V!T 3C CS� <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 /> OAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEQ,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TP <br /> RKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'$HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PER FORMAN F THE WORK FOR WHK:H THIS PERMIT.IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> rF CALIFORNIA." <br /> ipplicarWas aluue --"Tine !G C ! Dale � 1 <br /> BILLING INFORMA11ON: <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 <br /> s�this responsibility for the Wing by signature avid date below. ,e�L <br /> NAMTITLE G Sei-V"tde PHONE# <br /> ADDRESS -7' <br /> SIGNATURE DATE <br /> RECFI '=D <br /> VL:�ar�^ <br /> 2 6f 20P <br /> P <br />