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SAN JOAQUIN <br /> O QUiN Environmental Health Department <br /> - - C O U N T Y ..__ . . . . <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 /> D TANK RETROFIT U PIPING REPAIRIRETROFIT U UDC REPAIR/RETROFIT U COLD STARTI UPGRADE <br /> F EPA Site # Project Contact & Telephone # t <br /> C Facility Name I `� ,t' Phone # <br /> I � <br /> L Address � <br /> I Cross Street — <br /> T Phone # <br /> Y Owner/Operator � n � { � � <br /> Phone # <br /> C Contractor Nameco 0 ( t <br /> 0 ` � <br /> N Contractor Address CA Lic # op J Clas <br /> T ud <br /> R Insurer Work Comp # "Igzc ATICC Technician's NameExpiration Date R ICC Installer'sName ) � �� ` Expiration pate , j <br /> Tanks stem work area Date UST <br /> Y Tank Size Chemicals Stored Currently Installed <br /> (i.e . 87 piping sump, 91 leak detector, UDC 1124 otc.) _ <br /> LUq U. <br /> N <br /> K 9 UT 112 ( X <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ( Be Attachment With Conditions) <br /> A III <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAW'S, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING. 1 CERTIFY THAT IN <br /> THE PERFORM CE 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 CO NSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY <br /> THAT IN THE P ORMANCE OF THE WORK FOR WHICH THIS PERM IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA. � r <br /> Applicant's Signalur Tits 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 /> ackno edge this responsibility for the billing by signature and date below. <br /> IVAMEN� r lCaca r 1 WQi..-. TITLE_ 11 ��9 PHONE ) t I . i <br /> ADDRESS 12JO C <br /> (SIGNATU DATE l fl2dL_— <br /> i <br /> 2of6 <br />