Laserfiche WebLink
i RIIcCL LiO4�A <br /> ENJIRCNMENTAL HEALTH DIVISION • <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM lT{E APPROVAL DATE�KN NRC. INN ANY SHADED AREAS, 2ND::\T PERMIT TYPE BELOW: <br /> _TANK RETROFIT __�_ P"TNG REPAIR <br /> G PROTECT CONTACT 6 TELEPHONE S <br /> EPA SITE a � + _ <br /> �J�' N p PHONE a(20c% 83Z ^� <br /> - FACILITY NAME V-o'ca 3(c� 0 l <br /> A <br /> C I ADDRESS TI) <br /> L I CROSS STREET <br /> I I PROF- <br /> T I DWNER/OPERATOR <br /> C ICONTRACTOR NAME S�{�LY'g (11 �r �N at'N <br /> PHO-_ U_OCA/ C oX O `J <br /> O I CA LIC asLj!S 710 I C..AS <br /> C <br /> �ok <br /> N I CONTAACCOR Anoaes5�� (�1 k <br /> T I WO2Z.CCMP.0 <br /> R I INSURER <br /> A I <br /> C I OTHER INFORMATION <br /> PHONE 3 <br /> R I I PHO: <br /> �"'I 1I1111111111111111111111111111I CHEMT-J :.L <br /> CHEMICALS STORED CURRENY/PR=VSOUSLY DATE US: INST <br /> TANK SIZE LED <br /> TANK ID a 2 taaS 1LtiE 1A Y `?' D N' <br /> C/f", 41�tU , I [-1t'rso1wF <br /> T 1 39- vein c"n 43Z 1 + I Rtc>s.n/EI� - ��---I <br /> A I 39- l 7 I <br /> 39- <br /> .,< 39- <br /> 19- I <br /> I <br /> 39 <br /> —1111111111111111111111111111411111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 I <br /> L1 _- APPROVED APPROVED WITH CO.NDITION(S! DISAPPROVED 1 <br /> 1 SE' ATTACHMENT WITH CONDITIONS) DATE <br /> A JA ! <br /> N I PLAN REVIEWERS NAY <br /> —11111111111111111111 I I I I I I II I IIIIIIIIIIIIII11111111111111111111111111111111111111111111 1111 Illlllllllllll <br /> TS' FOLLOWING: ^I CERTIPY THAT :N <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES' STATE LAWS, AND RULES AND REGULATIONS r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES SUCH A <br /> PERSON SUBJECTTOORKERFSTCOM?ONSATOIONWLANS OF CALI OPNIAHICH THIS PERMIT S+LSSUED' I CONTRACTO¢SyHIRINGG OROY AWfSUDCONTRACTItiGVSIGNAT'J? C`RTL SSOTHE CFOLLONI:IG: <br /> I rERTIFY THAT IN THE PERFORMANCE OF THE WORK F WHICH THIS PERYI: IS ISSUED, 2 SHALL EM?LO'! PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CAL:FO <br /> TITLE <br /> APPLICANT'S SIGNATURE: <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended bermit <br /> permit payment coverage per tank. ife must aparty cknowledge this esignated below responsibility for the ebilling <br /> applicant, e.g- pronerty owner, part <br /> Y 4 d ` <br /> by signature andel date below. Y,,q <br /> oaddress <br /> hone numberNam <br /> Signature � <br /> Ab <br /> EH 23-0038 C^%^ ,�,� ,,��Mn , /'� ,�./ < o <br /> 1 <br />