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SANJOAQUIN <br />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 />QKTANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # Pl" O 22 00 60 Project Contact & Telephone �i3� <br />O <br />I <br />Facility Name C A GK O14 ,4 5 � Phone # 2 d9 8 <br />L <br />Address 264::50 >` r/ SD/V r�A, O G i o CA 6 <br />Cross Street <br />T <br />Y <br />Owner/Operator CA4 JFK Aq /y/ /L! DEPT Phone # �z d9 983 _533 t <br />o <br />Contractor Name K AA71 , Phone # L p <br />mac, 1F3z- oz 16 <br />NContractor <br />Address 27 �!S SldE/,{Gt/IN R �E.� L(/r1/TU$ CA Lic #�� Class <br />R <br />Jr e^ D <br />A <br />Insurer CA Lf EP rA NSuR�rn1 GG ©, Work Comp # �6 _835? D— <br />QICC <br />Technician's Name $FRN R LSO/�G5�$zq�13 Expiration Date <br />R <br />ICC Installer's Name <br />51AA h DZ -!50N 5252gq.3 Expiration Date 6), 7_zp 23 j <br />Tank system work area Tank Size Chemicals Stored Current) Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) y <br />Installed <br />T <br />15000 4440 Gt ST F �L <br />/5pro 4G. <br />F Zq <br />9 3 <br />A <br />N <br />K <br />P <br />ElApproved Approved with conditions ❑ Disapproved <br />L <br />A <br />(See ac h ent With Conditions) <br />N <br />Plan Reviewers Name1 _ 0 / <br />Date 30101 I. <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 OF E WOR FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF <br />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 belling by signature and date below. <br />NAME FIGHA2i7 /list 1 c7" TITLE GdFD PHONE# <br />SIGNATU <br />2of6 <br />