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S A N JOAQUIN Environmental Health Department <br /> COUNTY -- <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 /> ❑ TANK RETROFIT ,PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # ( k e:, V+,q <br /> � <br /> Facility Name �p C Phone # q _ � � � 7 & �yQ <br /> Addressg6 <br /> I Cross Street <br /> TPhone # o2D � � -- 001 <br /> Y Owner/Operator JOU 3 �,(� <br /> C Contractor Name Mqf.g t4m&(, Phone # <br /> 0 <br /> T Contractor Address oZoZ �,Q Gb {7 CA Lic # 3 (alY44 Classy k C16 <br /> A Insurer . � ��, Work Comp # 9613 <br /> C <br /> r ICC Technician's Name Expiration Date <br /> 0ICC Installer' s Name Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T <br /> A <br /> K .\ <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ee achment With Conditions) <br /> A L� <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE-W141-1 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 /> Applicant's Signature v • .R - itle ` 0 kU1L 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 responsib'il'ity' for the billing by signature and date below, c . <br /> NAME t4 kiZV 4 \[ t �/ Lrt 64tur�tJ _TITLE(1UW " bk( ''t--QV PHONE # 4b <br /> ADDRESS �v 0 C> C� U iLL(fl fU-e S �( L �1Ca� CAL �l F I <br /> SIGNATURE �� ( Lt� �Z�` � ' " �� C �'a✓L/ DATE <br /> 2of6 <br />