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IS A N U IN Environmental Health Department <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 /> XTANK RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIR/RETROFIT 0 COLD START/ EVR UPGRADE <br /> F EPA Site # PA p 22 0d 60 Project Contact & Telephone # <br /> 04S pN 805 q 3 —0 ;Z ( 6 <br /> C Facility Name CA A G/G 014 .Q 5j= Phone # Z b <br /> L Address 2, G6 fj CA <br /> TCross Street gob <br /> Y Owner/Operator Phone # 62 C2 c3 983 _ 5' 33 <br /> C Contractor Name Phone # C � p <br /> Q K �ntc , <br /> N Contractor Address z7y5 S/"'r �'/{ W/ N R via' I(/Jl r g CA Lic # �/2� 3 �r � ^ Oz 16 <br /> VFEAII! 10"Jqa ., C= A eel Class e ^ O <br /> RInsurer <br /> � CA LtF"o rA NSG[ III AA) GE O . Work Comp 6 .. 8 -T p Dl - l2 <br /> o ICC Technician' s Name 46rA 1hR 0L .SOI%t X50 52913 Expiration Date <br /> R ICC Installer' s NameBeleivAAn DL !5ON �`5252gg3 Expiration Date 6) 7 - ZD � Z3 <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 112, etc, ) y Installed <br /> T IS000 4iF4u ST F L- L- �5 D00 f1G. C" zel r 9 3 <br /> A <br /> N <br /> K <br /> —I <br /> P El Approved Approved with conditions ❑ Disapproved <br /> L (See ac ent With Conditions ) <br /> A <br /> Plan Reviewers Name �' �� Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE 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 : "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 OFII.I WOR FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title 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 /GHA2i7 M .I&7, TITLE G D PHONE # Z&Os) �myrZ— DZ (� <br /> ADDRESS Z7�f-J� . S 1ej< W11U /-i VE, /i!N/ T #8 VE/ I�A, C ,4 3003 <br /> SIGNATURE DATE <br /> 2of6 <br />