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Environmental ea'Ith De pa gnent� '�/Y <br /> SAN JOAQUIN ►- ` � LJ <br /> COUN I Y <br /> UCi 0 X017 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT P._NVi10(`li,�t:;,IT^' "�AL:I <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: `\ <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD STARTIEVR UPGRADE <br /> (ev,vzJ'5cu�1 <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name j'' v\ <br /> (Phone#> <br /> Address I C� • 2 G `I.�YJ <br /> I Cross StreetW(-Asan <br /> T <br /> Y Owner/Operator 1. •,& . • Phone# <br /> oContractor Name i. ec �tG Phone# 5:2_7 ' ._c, �c% Z <br /> T Contractor Address p &u c ��,J ) Qct()III CA Lic# �(s Zji(� Class11(17- <br /> R <br /> 1d Z <br /> A Insurer liVli i! .' 10 C�'�S'A6, Work Comp 610NCO) -.,?S;6 <br /> T ICC Technician's Name _, cL Expiration Date q_zq•-I <br /> R ICC Installer's Name G'.t� ctln Expiration Date -j( j19 <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 i _� Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date �f�7/�J A <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 ����t fln'rL Dale �( �J'7 <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. a <br /> Loe � Je SL.)NAME G <br /> ADDRESS �� d - t <br /> 1 <br /> SIGNATURE /^ DATE <br /> 2 of 6 <br />