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. f t� � (� Environmental Health Department b <br /> CoinNT * . <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM TH PPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT: ❑ PIPING REPAIR/RETROFIT. �JDC REPAIR/RETROFIT , ❑ COLD START/EVR: UP 'GRAPE <br /> F EPA Site• # ' ; Project Contact & Telephone # <br /> A <br /> C FacilityNam Phone # <br /> t <br /> L Address <br /> T <br /> Gross Street . <br /> 1' Owner/Operator Phone # <br /> C Contractor Name (�, /I' Phone # �p -� <br /> D . <br /> T Contractor Address . CA Lic # Class <br /> A Insurer Work Comp # <br /> T ICC Technician's Name Expiration Date <br /> j <br /> R ICC Installer's Name ( Expiration Date � ` s <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> . . e <br /> 1 <br /> t <br /> E <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se Attachment With Conditions) <br /> A, i i ` € <br /> N Plan Reviewers Name •: Date I I Z O Z <br /> t <br /> APPLICANT MUST PERFQRM 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 t <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 WOR FOR RICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS f <br /> OF CALIFORNIA. " }t <br /> Applicant's Signature TIU 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 TITLE PHONE # <br /> ADDRESS } <br /> t <br /> SIGNATURE DATE <br /> 1 <br /> I <br /> t <br /> t <br /> t <br /> 1 <br /> 2of6 <br /> r <br />