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SAN JOAQUIN Environmental Health Department <br /> coul`iTY . <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 # xvre4� FA~hA <br /> A <br /> D Facility Name ' Phone # ROO <br /> I Address 1. <br /> I Cross Street T0 JL <br /> Y Owner/Operatoraf/ G Phone # �- O 3 (8 Q <br /> C Contractor Name 'r' VrV C ys Phone # 3 Z <br /> 0 <br /> T Contractor Address dOvSt CA Lic # Class <br /> t <br /> AInsurer ��i,� a,Q Gl o�„t Work Comp # CCwyool - D <br /> T ICC Technician's Name � a„` ,Z a awc , Expiration Date t� ZS- <br /> RICC Installer's Name r� a. � iL jwe. c+vv%� Expiration Date t t tr <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leek detector, UDC V2, 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 <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 FOPWHICH THIS PERMIT IS ISSUED, I SHALL E LOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" <br /> Applicant's Signature Title " W Date 2 <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 ✓� i ,..•�, ✓ut' TITLE 1:91.Y ��I7TYPHONE # l " ` ! G " '✓ J 2 <br /> ADDRESS qq,0 �A) AMG 0 <br /> SIGNATURE L d4Z DATE Z <br /> 2of6 <br />