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ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGR( TANK RETROFIT, TANK LINING, OR PIPING REF 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 '—� PIPING REPAIR APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF 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 THI PERMIT -S—I-SSQEO, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPEEN�FNSATIO LAWS OF LIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN OFHE P FORMA OF THE RK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'SCOMP+ APPLICANT'S SIGNATURE: I�e 1` _�\,/ TITLE -3 DATE l/ T BILLING INFORMATION: Indicate the responsible party to be billed for additional PNS-EHO staff time expended beyond permit payment coverage per tan;-- If the party designated below is different than the ermit applicant, e.g. property owner, the party must acknowledge this responsiL'lity for the biIL'ing by signatur date bel Name Mailing Addr ss / �( )ay Phone N er Signature -H 23-0038 1 EPA SITE # PROJECT CONTACT & TELEPHONE # F A FACILITY NAME ` / PHONE # r % C I ADDRESS 1--- L CROSS STREET\ T OWN /OPERATO PHONE # C 0 CONTRACTOR NAME C%tti t--t'SLC_C� PHONE # N T CONTRACTOR ADDRESS2� Q - � CA LIC # �C V CLASSG4 �. R A INSURER WORK.COMP.# C OTHER INFORMATION T 0 R PHONE # IIIIIIIllI11111111111111111I1I TANK ID # 39 - TANK SIZE PHONE it CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTA'_.ED T 39- A 9- N 39- K 39- 39- 39- lIII I P L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED A (SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME DATE lIIllillllllllllllll II II I I II II 1 II I 111111 IIIII 1 II I I I 1 11 I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF 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 THI PERMIT -S—I-SSQEO, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPEEN�FNSATIO LAWS OF LIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN OFHE P FORMA OF THE RK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'SCOMP+ APPLICANT'S SIGNATURE: I�e 1` _�\,/ TITLE -3 DATE l/ T BILLING INFORMATION: Indicate the responsible party to be billed for additional PNS-EHO staff time expended beyond permit payment coverage per tan;-- If the party designated below is different than the ermit applicant, e.g. property owner, the party must acknowledge this responsiL'lity for the biIL'ing by signatur date bel Name Mailing Addr ss / �( )ay Phone N er Signature -H 23-0038 1