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' APPLICATION FOR UNOERGR. TANK RETROFIT, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BE ON: <br /> _TANK RETROFIT _ PIPING REPAIR qV <br /> EPA SITE # PROJECT CONTACT 6 TELEPHONE " / <br /> F FACILITY NAME ( ' PHONE 9 <br /> A OC✓i <br /> C ADDRESS / O <br /> I <br /> L CROSS STREET <br /> I <br /> TOWNER/OPERATOR i PHONE <br /> C I CONTRACTOR NAME PHONE p a O rA - 4U1 - 337 <br /> N CONTRACTOR ADDRE4S CA LIC % O CLASS <br /> T <br /> R INSURERql( WORX.COMP.,YI. � ��g7�0/ <br /> v'r <br /> A r .. i <br /> C OTHER INFORMATION <br /> T <br /> OPHONE 9 <br /> I <br /> R PHONE A <br /> TANK <br /> TANK ID R TANX SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY FOATE VST INSTALLED <br /> 39- <br /> T 39- <br /> A 39- <br /> N39- <br /> X 39- <br /> 39- <br /> 39- <br /> P <br /> P VVWAP pROVED APPROVED WITH CONOITIONISI DISAPPROVED <br /> A I ,.I1 I , I fS`E A,q.1TA^CH_ME�NT WIT���///��� NDITIONSI <br /> N PLAN REVIEWERS NAME 1 lam/. �J *� �l`TTFC/LJV+ DATE <br /> ............. .�������������������� <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PSvMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CAL:FORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I S L EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALI IJ(�A.']/L7� //��/yJ�/V/A/,/,J� <br /> APPLICANT'S SIGNATURE: X i[/ U( I�� TITLE +C '' <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond <br /> permit payment coverage per tank. If the party designated below is different than the permit <br /> applicant, e.g. property owner, the party must acknowledge this responsibility for the billing <br /> by signatu d date below. <br /> Name address phone number <br /> Signature <br /> EH 23-0038 <br /> 1 <br />