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SA KrJ O A Q U I N Environmental Health Department <br /> i0UNTY <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 /> C�'t'ANK RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIRIRETROFIT 0 COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # �(�( ' k4r4k 400 • 36, 1 - &$2j <br /> � Facility Name f:: A i O %rOL4jkA Phone ;0 9Cq - $� . Zci(00 <br /> L Address 61[, 66 HVdfit t/UAl 'Ti„p (/A <br /> T <br /> Cross Street <br /> Y Owner/Operator Ped )( 61ro " Phone # <br /> C Contractor Name BA c�k ?94yv i n4, Phone # <br /> 0 <br /> N Contractor Address ?gyp +' ?iY�d�ti CA Lic # 34 (oS" 'j�" ClassA 13 clo ' HOLZ <br /> A Insurer lsixk &)w 1q" 6 Work Come # clOM 22 1 <br /> T ICC Technician's Name <br /> (� hi Expiration Date 5 /3 / 7,3 <br /> R ICC installer's Name &rnr'GtubthP*ry Expiration Date ( l fZt / 2. Z <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e . 67 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> T Di�S 1 Narts O Va � v� n t PI t + +� 6� <br /> A VjYe t 2 IW #Wlti' - OF Uajof h to rJlt tAAk4 <br /> N <br /> K pit 010 3 - Or- tp #IVJe h JA 6 ; vdAtes,eA <br /> IP ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> , n <br /> N Plan Reviewers Name Date " L � <br /> APPLICANT MUST PERFORM 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 <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." <br /> GCApplicant'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 <br /> billing by signature and date <br /> below. <br /> NAME DOLJ � Iy W ( yw*�t ( � l ITLE �� Y � � ' PHONE # <br /> r <br /> ADDRESS A 3 0 l `L"S /YV'C� L-G- t tto 1 'a <br /> SIGNATURE — --- DATE <br /> 2of6 <br />