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SAN _ 10 A Q U I N Env , . � nmental Health Department <br /> COUNTY RECEIVED <br /> APPLICATION FOR UNDERGROUND STORAGE TANK �iAk 2 0 2018 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> ENVIRONMENTAL HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOWPERMIT/SS {� rrFF <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR <br /> F EPA Site # Project Contact & Telephone # : 0 1 fr)s <br /> A <br /> G Facility Name \0 .� Phone # <br /> I Address b d _ (� <br /> TCross Street <br /> Y Owner/Operator Phone # <br /> 104 <br /> o Contractor Name _ kU ` � Phone # 72 <br /> N <br /> T Contractor Address CA Lic # Class <br /> AInsurer Work Comp # <br /> TICC Technician 's Name Expiration Date ! L4 ( � <br /> R <br /> 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 1 /2, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <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 PERFOR N E 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 Signatur Title_ - - � '� ► ' �i � DateA2 <br /> / <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 responsiibbilliity for the billing by ignature and date below. C f <br /> NAME \ Y'� S TL C �- l� PHONE tt �� L� CS <br /> ADDRESS <br /> 1 V <br /> SIGNATURE DATE <br /> 2 of 6 <br />