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SKJ O A Q U(N Environmental Health Department <br /> —COUNTY-- <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM TIJE PPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT 0 PIPING REPAIRIRETROFIT DC REPAIRIRETROFIT 0 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# gah ZpQ j GI_ 11011 <br /> C Facility Name , Phone# 2 '-7-•60L> <br /> L Address 34 O g, CA `3 S"36 4 <br /> 1 Cross Street <br /> Y Owner/Operator -� ,$I >1 Phone# <br /> oContractor Name tQ p . ���, ,,� o�*�r✓,�P.3 - Phone �y,�- t��{�. pgp3 <br /> T Contractor Address 3 %A Q CAT5,r6 4CA LiC# if 00 yvz/ Class <br /> R A Insurer STC�--tt e _CA�tqEv1 Jn p#`{ Work Comp 207_r- <br /> Q. !4» 1LS'W'Qna� ZI <br /> T ICC Technician's Name Expiration Date 2�2� <br /> D Installer's Name <br /> R ICC i ll CU��,(� S,r�c�� Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> p.e.87 piping sump,91 Ioek detector,UDC W.etc.) Installed <br /> T C) ' - 14-2 v�)C <br /> N U C s'a- ( <br /> KIt�t2.- <br /> u� 134/y u o, /s,./4 <br /> p Approved with conditions Disapproved <br /> L (See Attac ant With Conditions) <br /> A �y <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN CC ANC WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTM NT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 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� <br /> Applicant's Signature I- Title C-7—0 Date D�L <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 responsibility for the billing by signature and date below. <br /> NAME TITLE 1Q4V,,'e✓' PHONE#C�z D'Q -S j q"4101V <br /> ADDRESS <br /> SIGNATURE J� �' DATE V 2- <br /> 3 of 6 <br />