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AU I N Environmental Health Department <br /> OUNTY <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 REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# ,h ' <br /> C Facility Name U Phone# <br /> I Address -2-- i <br /> I Cross Street <br /> T <br /> Y Owner/Operator f♦ re Fj Phone# <br /> oContractor Name Phone# <br /> T Contractor Address 2 CA Lic# 312,bq Class'pj fq (2A0 1 <br /> R A Insurer 9 Work Comp# <br /> T ICC Technician's Name Expiration Date <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Tank Size Chemicals Stored Currently Installed <br /> T <br /> A <br /> N <br /> K r <br /> P pproved with conditions ❑ Disapproved <br /> L (Se Attachment With 5 itions) <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 FOR WHICH THIS PERM IS 1�.I EMPLOY PE SONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." 1 <br /> Applicant's Signa re. S_•-' � Title } 1�� Date =14r <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 si ure and d to ow. <br /> NAMEP�/� <br /> 1 nQ `�� TITLE PHONE# <br /> ADDRESS ` � M +i t- .� <br /> SIGNATURE DATE <br /> 3 0f 6 <br />