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S A N JOAQUIN Environmer lift.GhEbIvrL Ii <br /> - COU N T Y ----- <br /> OCT 0 8 2021 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT F= NVIRONMENTAL HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROMTHE APPROVAL DATE. INDICATE PERMIT TYPE BELOW":FRMIT / SERVICES <br /> TANK RETROFIT D PIPING REPAIRIRETROFIT D UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> X 14 <br /> F EPA Site # L4D0 j �� Project Contact & Telephone # ' a awe4eZ zi y _ o _ r} ,?Os? <br /> � Facility Name 2 t p Ar-- 0111 N / Phone <4461 �Q 30 <br /> I Address 7 q ,? ,D J oC <br /> L <br /> 1 Cross Street CC61vt t <br /> T <br /> Y Owner/Operator eC + 51 V1 Phone # aoi? 5" '7 S - 4al y <br /> C Contractor Name � , ut,AiWt i- Ile aA, .�or✓/ CES 91A C. <br /> Phone Y -40 - 0303 <br /> 0 <br /> T Contractor Address 36 1 4 t v� C { ��, % too ,, 61 S Y rCl 9 CA Lic # / 0 o.s 4/ V y Class A <br /> R Insurer vtrWork Comp # 9 2 f k 7 98 -LA S11CcCivy eH15 <br /> C ICC Technician's Name Expiration Date Zoz <br /> T CUct �Q ( v, e CIrC c 'i ( ' / ` 3 <br /> oICC Installer's Name C %j Expiration ate I- Y - ZO Z <br /> R ND <br /> C= � C �v � � tlMC � 2Z 3 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (.e. 87 piping sump, 91 leak detector, UDC W, otc.) Installed <br /> T I ( t 3 � 5� 6 � �01 <br /> P Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions ) <br /> A <br /> N Plan Reviewers Name Date <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 AGENTS 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 TC <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'" lI Q <br /> Applicant's Signatur� y Title �✓ Date 168 (� 20Z <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. / \ p <br /> NAME j \ WA 1 PCS � 31 VI P f"< TITLE C E V PHONE # ( Z d �1/ S 4�C) <br /> ADDRESS Z q 3 O <br /> SIGNATURE DATE 10 '0 8 ' 22 <br /> 2of6 <br />