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SA N 10 A Q U I N Environmental Health Department <br /> ---COU NTY-- <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM tHE,4PPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFITUDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# , 0 Ir 'D. 4-0 Q —OfJ <br /> A <br /> O Facility Name 5 }-1 L L I—S� Phone# <br /> I Address -7 11 <br /> L <br /> T Cross Street -44 w a Y S� <br /> Y Owner/Operator J O f A-t J G+ -Tr2- .1J Phone# (409W6 -000 <br /> oContractor Name LI T V Phone# <br /> T Contractor Address 'Z r� W (G k.l rwj CA Lic# Class <br /> R <br /> A Insurer Work Comp# <br /> C <br /> r ICC Technician's Name Expiration Date <br /> Q <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) j <br /> N Plan Reviewers Name � 1 L 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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature ""'� Title ) N F�L 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 <br /> the billing by signature and date below. <br /> NAME �C� ��7'N�/IZ/4'� TITLE 0✓N � IL PHONE# <br /> ADDRESS -7 1, w , T�E S Q L l L7 0 IU q ZO b <br /> SIGNATURE____ DATE <br /> 2 1 20 g <br /> 2of6 <br />