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08/19/1992 05:05 70737420 NDE ENVIRWAENTAL PAGE 02 <br />ENVIRDNMENTAL HEALTH DIVISION <br />APPLICATION FOR RINOERGRCUMD TANK RETROFIT, TANK LINING, OR PIPING KEP PERMIT <br />THIS PERMIT EXPIRES 90 CATS FROM TNR APPROVAL DATE- DO NDI URITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE AELw- <br />—TANK REPAIR/RETROFTY TANK LINI. D1D1,1.... Rc X &JG4X IDLiLa Te/L- R'Y44"' <br />BILLING INFORMATIONt <br />Indicate the responsible party tD he hilted far additional PHS -END staff time expended beyand permit poynomt coverage per tank, If the <br />party designated beta. is different than the permit applicant, e.N* property inner, the party Must acknowledge this responsibility far <br />the bitting by signature and date bolo,, <br />Hailing Address <br />Day Phone wwber t <br />EN 23-0038 <br />1 <br />EPA SITE P <br />PROJECT CONTACT i TELEPHONE 0 <br />AFACILITY <br />NAME ���` AI �•� <br />'NONE/ <br />1 <br />ADDRESS L7 I-, J! <br />L <br />CROSS STREET <br />1 <br />T <br />OWNEN/MRATOR <br />PHONE 1 <br />* <br />sov�/�.0 ca zPer�471a..a <br />916 <br />C <br />D <br />CONTRACTOR NAME <br />PHONE # <br />- P6 Y- of Ifo <br />N <br />T <br />CONTRACTOR ADDRESS L_ ,� �tijo _WIE r <br />CA LIC # <br />CLASS <br />R <br />INSURER ° / �'P_ 4J."v'r <br />CC7lN-# <br />A <br />C <br />OTHER INFORMATION <br />i <br />0 <br />A <br />PHONE # <br />PHONEW TANTANK <br />SIZE CHEMICALS STORED CIIRRlRTLY/PREV[[KKLT DATE OST INS7AlLEi139- ry 9 <br />T <br />39-A <br />t.44,W&4 <br />39-N <br />K <br />39- <br />39- <br />39 - <br />39 - <br />II II <br />P <br />L APPROVED ARPRWEO WITH CGNDIT90N(SI _ DISAPPROVED <br />A <br />,SEE ATTACHMENT WITH CM ITIONSI <br />N <br />PLAN REVIELERS HANE DATE <br />1IIIlIII11111IIlIIII I I tll[II <br />APPLICANT MUST PERFORO ALL WORK IN ACCORDANCE WITH SAW JOAQUIN CWNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAourm CWNTT PVGLIC HEALTH SERVICES. OWNER ON LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR UHICH THIS PERMIT 15 ISSUED, <br />I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CAU FMNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />•1 CERTIFY THAT IN THE PERFCAMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: t �� TITLE diY✓Ri7Tnra Rv OA7E _Z-0-97 <br />BILLING INFORMATIONt <br />Indicate the responsible party tD he hilted far additional PHS -END staff time expended beyand permit poynomt coverage per tank, If the <br />party designated beta. is different than the permit applicant, e.N* property inner, the party Must acknowledge this responsibility far <br />the bitting by signature and date bolo,, <br />Hailing Address <br />Day Phone wwber t <br />EN 23-0038 <br />1 <br />