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F <br />A <br />I <br />L <br />I <br />D <br />N <br />T <br />R <br />A <br />C <br />T <br />O <br />R <br />T <br />A <br />N <br />K <br />P <br />L <br />A <br />N <br />APPLICATION FOR UNDL-ROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />,TANR RETROFIT / ` PIPING REPAIR <br />EPA SITEKCAL <br />I PROJECT CONTACT & TELEPHONE # Z� fl <br />FACILITY NAME u <br />' •.L <br />PHONE <br />ADDRESS / S <br />Ave— <br />CROSS STREET Gha.-.J„r W, <br />! <br />I OWNER P£RA <br />I PHONE N <br />! 8 c � �-�', n <br />D;S�-, v✓I�r;• <br />I �G�i Y Sso ev&c% r <br />W 1_ <br />NTRACTOR NAME � e. -m <br />- PHONE V <br />c� �-► r�-c��-y_��;-�-, <br />CONTRACTOR ADDRESS %. -/ O E <br />/ 7 <br />y,= ^ �_.� <br />t , -A LIC M j�, % •1WO� �1 I CLASS /I <br />/'/ <br />-� <br />INSURER ; <br />_ WORK. CLOMP. 0 <br />OTHER INFORMATION <br />! I <br />I <br />I PHONE <br />PHONE S I <br />illlllllllllllllllllllllillllll� <br />TANK ID p <br />"�`t <br />TANK SIR£ <br />CHEM CALS STORED CURRENTLY/PREVIOUSLY DATE S)' INSTALLED <br />(�t; <br />f=� �5,...1,�, " ` tc 1 z". e- x7 <br />/ I <br />9- ! <br />] 39- <br />I <br />39- 1 <br />39- <br />] 39- 1 <br />39- <br />I I <br />! 39- I <br />39- <br />! <br />39- <br />] 39- 1 <br />! <br />39- <br />11 <br />11111f1111111111111lIIIlf1lllni11u1111n1urlrr11 iflnlnu <br />fill III Ili ! i]llllulluluIIIIHInn1ilIJlllulin IIIIIIll+ <br />,^ APPROVED <br />TH <br />ONDIT=O DISAPPROVED <br />W <br />Ai� <br />OND T'^IONS)PLAN <br />REVIEWERS NAME <br />'llylllll <br />DATE <br />IIII lllllllllllllllllil II1! <br />11 1111111 <br />III111111111 IIIIIIIIIIIIIIIIIIIIIIII I 1111II I11t1111111111 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY 0?-JINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN j <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 <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.• CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:! <br />"I CERTIFY THAT I:7 THE PERFORMANCE OFTf;E WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." � �.---� <br />APPLICANT'S SIGNATURE: <br />BILLING INFORMATION: <br />TITLE (.. C tU DATE <br />Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond <br />permit payment coverage per tank. If the party designated below is different than the permit <br />applicant, e.g. property owner, the party must acknowledge this responsibility for the billing <br />by signature and date below. J/p <br />Name St{tx Q,saddress j�' ey <br />�tMA $!� � phone number F-r�' -554- �.X t-> <br />Signature T <br />�17& <br />Qj <br />F.N 11-nnin <br />1 <br />