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an t <br /> Environme to SAN ' JOAQUIN lM l EI �9 1s. � <br /> COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK OCT 6 8 2019 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> �NY,IRONMENTAL HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE , INDICATE PERMIT TYPE �- <br /> ❑ TANK RETROFIT [I PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/RV�Ru ,�� NT <br /> F EPA Site # Project Contact & Telephone # <br /> � Facility Name . L� / /���/j�C � �� �n7�/� C/� !3 0 Phone # <br /> L Address ale 1f�pevG ep71v vQdo <br /> I Cross Street <br /> T <br /> Y Owner/Operator eLiC/ � Phone # �07 <br /> C Contractor Name Phone # <br /> O <br /> T Contractor Address � � �px CA Lic # 7 ,; Class <br /> S% f1 cr/v <br /> R Insurer Work Comp # <br /> A <br /> TICC Technician ' s Name ����� / Expiration Date <br /> 0 ICC Installer's Name ael � �—�� 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 ❑ ApprovedApproved with conditions ❑ Disapproved <br /> L (S e A achment With Conditions ) <br /> AT�l <br /> N Plan Reviewers Name -� Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE TH 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." p <br /> Applicant's Signature �'�� ` Title C-Q/!/ T' 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 the billing by signature and date below, <br /> NAME/� ��/T TITLE PHONE # O a� / Y �� oZ <br /> ADDRESS � � !/ i P �(CI L/ V G/� 1/ // � . CA <br /> SIGNATUREDATE <br /> 2 of 6 <br />