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ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGD TANK RETROFIT, TANK LINING, OR PIPING R40 PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />_TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR )L Lf%)K 19A jr.C7c/C R�FP[.vcr.y�-7 <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional PHS-EHO 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 bitting by signature and date below. <br />Mailing <br />Day Phone Number <br />Signature <br />EH 23-0038 <br />1 <br />PROJECT CONTACT 8 TELEPHONE # <br />ME-/ c� <br />PHONE #may- <br />% yG0 u.�'T-I'-Y a6✓6TTORPHONE <br />F <br /># <br />,i00T>a 14-.0 G0210DIZ-4T70,0 <br />?16-63/-72// <br />C <br />0 <br />CONTRACTOR NAME j,�-, A, OL06 . N�� <br />PHONE # <br />800 - 9G Y -o/ So <br />N <br />CONTRACTOR ADDRESS IV7f1 X177-441214 T <br />CA LIC # <br />CLASS <br />T4,f�k <br />STl <br />R <br />INSURER CO, / N• 96zV L <br />A <br />WORK. COMP.# <br />C <br />OTHER INFORMATION <br />T <br />0 <br />R <br />PHONE # <br />PHONE # <br />TANK 10 # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- V Z M10lo K/M(1 9986 <br />T <br />}2NLiIA0,i0 <br />39- rF IC u[.4n— 9 So yi„y�yL,p <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />I <br />APPROVED _ APPROVED WITH CONDITION(S)DISAPPROVED <br />(SEE ATTACHMENT WITH CONDITIONS) <br />PLAN REVIEWERS NAME <br />DATE <br />APPLICANT <br />MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN <br />JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AG'ENT'S SIGNATURE <br />CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY <br />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 />"1 <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, <br />I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />J <br />APPLICANT'S <br />SIGNATURE: ��/ TITLE <br />DATE <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional PHS-EHO 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 bitting by signature and date below. <br />Mailing <br />Day Phone Number <br />Signature <br />EH 23-0038 <br />1 <br />