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ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGI t TANK RETROFIT, TANK LINING, OR PIPING RE PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: _TANK REPAIR/RETROFIT TANK LINING ✓PTPINr, PPPATP 1 BILLING INFORMATION: Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tar.:. If the party designated below is different than the ermit applicant, e.g. property owner, the party must acknowledge this responsi'r lity for the billing by signatur date bel Name U Mailing Addr ss Day Phone N er �a Signature EH 23-0038 1 0 I. EPA SITE # PROJECT CONTACT & TELEPHONE # 33 � F FACILITY NAME9� PHONE # % A ` b I ADDRESS 30 A _ L CROSS STREET I !� T OWN /OPERATO PHONE 3� — Jao C CONTRACTOR NAME `/ l ILG�� t / �–, 4� PHONE # 0 ' f l't C:C�k - N CONTRACTOR ADDRESS S'jZ4CCA LIC # i�GIC CLASS T VZ �. R INSURER WORK.COMP.#/� l A C OTHER INFORMATION T 0 PHONE # R I11111111111I1(IIIIIIIII!lllll PHONE # TANK 10 # 39 - TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INST:'_LED T 39- A 9- N 39- K 39- 39- 39- P IIIII APPROVED APPROVED WITH CONDITIONS) DISAPPROVED J (SEE ATTACHMENT WITH CONDITIONS) PLAN REVIEWERS NAME 11111111111111111111 II DATE II I II II I 11 1 (11111 Illll (11111 I+III APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS C= SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT. IN THE PERFORMANCE OF THE WORK FOR CH TNI PERMIT �I-SSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATIO LAWS OF LIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE P FORMA OF THE RK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CAL F RNIA. APPLICANT'S SIGNATURE: �� TITLE DATE � T 1 BILLING INFORMATION: Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tar.:. If the party designated below is different than the ermit applicant, e.g. property owner, the party must acknowledge this responsi'r lity for the billing by signatur date bel Name U Mailing Addr ss Day Phone N er �a Signature EH 23-0038 1 0 I.