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SAN JOAQUIN Environmental Health Department <br /> -- COUNTY - DEC 2 1 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT NVIRONMENTAL HEALTH <br /> F) FIRMIT / SFRVICES <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW. <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # <br /> A <br /> C Facility Name N(• zd Lit _ li A.l V �% ( �jz P h o n e # 3,6 c' <br /> L Address <br /> TCross Street <br /> Y Owner/Operator * ��,- �L 2E Q �{Z Y Phone # f CC*' - gaao - 7 <br /> C Contractor Name d IE� <tN4=t^,f46 �� orc{�.s '"� Phone # G` 73o }� <br /> 0 <br /> T Contractor Address 7j'd ( A"vV*v fs CA Lic # :300,2c ` E) Class ! G F W <br /> A Insurer g0h%,1.5 " L c" VOK41 CA= L716 - 0f� IItA Work Comp # 2 <br /> S -15 Z <br /> T ICC Technician 's Name {IC ,V-" cwf� - Vr:gZA5)(,► Expiration Date if <br /> RICC Installer's Name Expiration Date <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 El Disapproved <br /> L e ttachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date �� �` Z3 <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 PESONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> �--� tet/' w..i ` (;y =.r.G ;,.,•1, Z-� ,�:� L '�. <br /> Applicant'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 billing by signature and date below. <br /> NAME [. �� , <4 `"( Ccs. It k C- . TITLE A *k^A.� C,.eJ�ti �J PHONE # ' - -673c` " 01 <br /> ADDRESS <br /> SIGNATURE -�"- 7 r DATE <br /> 2 of 6 <br />