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AJOQ I Environmental 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 0 PIPING REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT 0 COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility Name -i v- Phone# 9 n4o <br /> I Address 2-570 t ;i , <br /> L <br /> TCross Street <br /> Y Owner/Operator Phone# <br /> o Contractor Name L, b[ Phone# <br /> N CA Lic# Class C <br /> T Contractor Address-2,%%-7 AJ Z 7 I <br /> R Insurer AC-61��teAr Sc! tvt ct Work Comp# 2Z fp <br /> A <br /> c ICC Technician's Name Expiration Date <br /> T _ <br /> R ICC Installer's Name S� v,M1 pr , Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 pang sump,91 leak detector.UDC 112,ete.) Installed <br /> Safi s <br /> T t ., . <br /> A y <br /> N <br /> P ❑ Approved ❑ Approved with conditions ❑ 1� ' d <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 pERFORMAN F THE WORK FOR WHICH THIS PERMIT IS kSSLIED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> �e <br /> �icanrs Signature 7itla V � 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 /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME QQS eCht TITLE �"C S�iViG�S PHONE# <br /> ADDRESS_j -7 /►1 11a14,4*Art— �r,('�sus'I) A 01 <br /> SIGNATURE DATE rZ ) 7 <br /> 2 of 6 <br />