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MF M <br /> E' tf L< Environmental Health Department <br /> SA WP] UI <br /> 5- NM JNMEINFUALIAE.� Affk' <br /> APPLICATIO O uNbtRGROUND 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 D UDC REPAIRIRETROFIT IPCOLD STARTIEVR UPGRADE <br /> F EPA Site # OU U Project Contact & Telephone # .02_ Z/G& d <br /> Facility Name Phone <br /> L Address 40 ( _ <br /> I Cross Street <br /> T j <br /> Y Owner/Operator Phone # <br /> C <br /> Contractor Name # t,/ ,[ f <br /> T Contractor Address - CA Lic # E" Glass <br /> R Insurer Work Cam # ` C <br /> Ap i <br /> T ICC Technician's Name � � Expiration Date <br /> R ICC Installers Name Expiration Date <br /> Tank system work area Tank Size rt Chemicals Stored Currently Date UST <br /> (),o. 87 piping sump, 91 look deleetor, UDC 1124 ate ) Installed <br /> Nenr o �, , .: <br /> iKI� r <br /> NZ <br /> i <br /> P FJ Approved 11 Approved with conditions ❑ Disapproved <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 I <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN <br /> HE PERFORMANCE OF THE WORK FOR N THIS PERMIT 15 ISSUED, i SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALI RNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN TH ORMANcA OF T 1E WORK OR WHICH THIS PERMIT IS ISSUED, I SHALL, EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> ` OF CALIFORNIA " <br /> Applicant's Sig tun <br /> BILLING INFORMAT(ON . <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 j <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME 4V1s* + 0g5 N .Jlly6 14 TITLE Lt *AWE/L PHONE # <br /> APDRESS_Z _ / S oe , toq]r gtz4,CJIQ A cog l S 33 6 <br /> i <br /> SIGNATURE DATE <br /> 1 <br /> I <br /> l <br /> 2013 <br /> < , F <br />