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J� APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br />THIS PET EXPIRES 90 DAYS FROM T' ?PROVAL DATE. DO NOT WRITE IN ANY SHADED 'S. INDICATE PERMIT TYPE BELOW: <br />_TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional PHS -END staff time expended beyond permit payment coverage per tank. If the <br />party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br />the billing by signature and date below. <br />Name <br />Mailing Address <br />EPA SITE # <br />PROJECT CONTACT & TELEPHONE # <br />A <br />FACILITY NAME <br />PHONf it <br />C <br />l <br />ADDRESS 5— <br />' o6�ri <br />L <br />CROSS STREET <br />I <br />` <br />T <br />OWNER/OPERATOR <br />PHONE # <br />Y <br />C <br />0 <br />CONTRACTOR NAME` <br />�l <br />PHONE / <br />f� <br />N <br />CONTRACTOR ADDRESS <br />CA LIC # <br />CLASS <br />T <br />G <br />R <br />INSURER <br />WORK.COMP.# <br />A <br />C <br />OTHER INFORMATION <br />T <br />0 <br />PHONE # <br />R <br />Illllllllllltllfll(IIII1111I11 <br />TANK ID # <br />PHONE # <br />TA K IZE CHEMICALS STORED CURRENTLY/PREVIOUSLY <br />DATE UST INSTALLED <br />39 <br />l — 6 e <br />A� <br />T <br />39- <br />— W&2 ,1 en !�/ n�nG <br />for <br />A <br />39- <br />�� <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />llll <br />P <br />L <br />APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />A <br />E ATTACHMENT WITH CONDITIONS) <br />N <br />PLAN REVIEWERS NAME <br />DATE Z] 03 <br />IIIllllllll(Illitlfllll1111 <br />II1111111111111111! I fill III IIII1 1111 11111 II 1 it 111111 Iili IIlI 111i111lllililllll <br />APPLICANT <br />MUST PERFORM <br />ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN <br />JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE <br />PERFORMANCE OF THE <br />WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I <br />CERTIFY THAT IN THE <br />PERFORMANCE OF THE 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 />i/ n./�� TITLE VYom_ C/fli7 "DATE O" <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional PHS -END staff time expended beyond permit payment coverage per tank. If the <br />party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br />the billing by signature and date below. <br />Name <br />Mailing Address <br />