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<`JOAQUIN Environmental Health Department <br /> OU NTY <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 REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# } l . hy 7—V k l <br /> A <br /> C Facility Name Phone#2Dq-C(-6q -82.96 <br /> L Address 2--lot) <br /> Cross Street <br /> T _ <br /> Y Owner/OperatorPhone# 2j-)el- q lj-ot*z <br /> o Contractor Name - Phone# .-SJ- <br /> N <br /> T Contractor Address 52-' CA Lic# Class <br /> ,4 <br /> A Insurer +�* , + Work Comp# 1 <br /> TICC Technician's Name Expiration Date <br /> R ICC Installer's Name _ � Expiration Date <br /> Tank system work areaDate UST <br /> (i.e.87 piping sump,91 leak detector,UDC 12,etc.) Tank Size Chemicals Stored Currently Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved with conditions ❑ Disapproved <br /> L (See ttachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date 12/22/25 <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 TH WORK FOR WHICH THIS PERMIT IS ISSUEQ�S qL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." ....� <br /> r <br /> pplicant's Signaiure Title "l- lar <br /> Data <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 /> acknowled a this re ponslbility for he billing by sign a nd at ow.. <br /> NAME TITLE �LR�] / PHONE# <br /> ADDRESS tI L flJGl <br /> SIGNATUR DATE /2, Z cS~ <br /> 3of6 <br />