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SANJOAQUIN 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 # <br /> Facility Namely,, Phone # 6 4 b � � ; 1 <br /> I <br /> L Address '3 <br /> I Cross Street 4;i f u <br /> T <br /> Y Owner/Operator �� > n Phone # NU4: ( � <br /> oContractor Name o �e itPhone # 4 0 = Xj; (46 <br /> T Contractor Address 3'a a � � CA Lic # lo') 4�}' Class $ C Woe <br /> A Insurer - Work Comp # �3ee M:om duzl <br /> T ICC Technician ' s Name G� �j Expiration Date <br /> R ICC 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 /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions ) <br /> A 1 <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 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. " I r � <br /> Applicant's Signature ( LCQ I-C�L2� Jr t�4A----) Title Cbu l « µlmb1414Date 10 <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. !� �s s�1 <br /> NAME N1 �(l�cc N c w � *U"tC �J TITLE �Vaku ` taace � � « ` 6 0 PHONE # , gtj� 60 <br /> ADDRESS l0 �t b 6) l) 111( �— '� U LQ ! L �'cJ� � Cin ` � c�--- <br /> SIGNATURE <br /> b� "� �- L-a-(�" DATE <br /> 2 of 6 <br />