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APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS , ANp RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THF FOLLOWING: "I CERTIFY THAT IN 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CE RTIFIES THE FOLLOWING: "I I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I $HALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' Applicant's Signature Date Z7 A! r2i BILLING INFORMATION : Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payme it coverage per tank. If the parry designated below is different than the permit applicant, e .g , property owner, the party must acknowledge this responsibility for the billing by signature and date below. NAME.MOE PACIFIC ENT TITLE`OWNER PHONE 4.(650)898-9C 51 ADDRESS.510 MYRTLE AVE #209 SOUTH SAN FRANCISCO CA 94080 SIGNATURE DATE 05/18/2021 2of6 > J 04A VIN c Environmental Health Department UST SYSTEM RETROFIT OR REPAIR (Submit minimum of 3 sets of plans & applications as originals will be retained by EHD) 1 . Site map enclosed ? YES [Y ] NO [ ] 2 . Submit copies of ICC Service Technician and/or Installer's certificate and all manufacturer training certificates for each person installing or testing any component that is repaired or replaced . Ensure a copy of the "Site Health and Safety Plan" is available on the jobsite as required by Title 8 . 3 . Detailed description of work to be completed . List components diagram drawn to scale showing location of repairs and/or replacements to be relf Tae airinr a replaced and attach a how this will be done. if A g ponent, describe ( 3ddiu� piping , UDC's, or other UST equipment, or performing tan top upgrade, use the UST Installation Application pages 4-8 as necessary for a timely plan review) : _REPLACEMENT OF SPILL BUCKET PRODUCT PW 1 -2100-EVR 4 . List of equipment to be used (Attach manufacturer's specification sheets showing third-party pproval ): OPW 1 -2100- EVR SERIES DIRECT BURRY SPILL CONTAINMENT BUCKET 5. Decontamination Procedures: a . Will piping be decontaminated prior to removal ? YES [ ] NO [NO ] b. Identify contractor performing decontamination : Name TANK-TIGHT SYSTEMS INC Phone (916) 753-0177 Address _9397 MIKO CIR , City _ELK GROVE Zip 95624