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ENVIRONMENTAL HEALTH DIVISION rr44-0 <br /> APPLICATION FOR UNDERGRq*TANK RETROFIT, TANK LINING, OR PIPING REPO ERMIT GD� <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br /> EPA SITE PRO.fECT CONTACT 8 TELEPHONE # n I c) Yl <br /> F FACILITY NAME II' PHONE # <br /> A 4 <br /> CADDRESS !40• <br /> I 00 L <br /> U <br /> L CROSS STREET <br /> I <br /> 7 OWNER/OPERATOR / (I 1, PHONE # - <br /> T I <br /> CO CONTRACTOR NAME �/ r/�l) ✓lS PHONE # i�(Y 3 7 <br /> CO <br /> N NTRACTOR ADDRESS CA LIC At CLASS <br /> T /l <br /> R INSURER <br /> ASL -r orn-m _ lJ`r' Y CX WORK.cOMP.# fT -I� _q`1 <br /> C OTHER INFORMATION <br /> T <br /> 0 PHONE <br /> R <br /> PHONE # <br /> 11111111111111111111111 f 111111 <br /> TANK ID 0 TANK SIIE CHEMICALS STORED CURR//ENTLY/PREVi OUSLY DATE UST INSTALLED <br /> 39• I Q� �;; 0 4 � By Qf_fGNG LYASo <br /> T 39- TY <br /> A 39- <br /> " 39- <br /> K 39- <br /> 30- <br /> IIII 1 I I <br /> D <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> ` '' (SE TTALHMENT WITH CONDITIONS) p <br /> N PLAN REVIEWERS NAME �/�—ieE/i�J//-� DATE O/4/7 1-7 <br /> IIII1111111I111111111111111! 11111111 IIIIII1111111I 111 11111111111111111111 II illl 1111111 IIIIII11111111111111111111111 <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. CUNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE 'WORK FOR 'WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO ''ORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTCR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> CERTIFY THAT IN THE 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: �•�,W�.-�,. \ ,) D.,-- TITLE S,_� DATE <br /> fLLING INFORMATION: <br /> �dicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the <br /> arty designated below is different than the permit applicant, e.g. property owner, the party mut acknowledge this responsibility for <br /> ie biLCing by signature and date below. <br /> ame qQ G <br /> ailing Address <br /> ;ay Phone Number "CS✓ALCp��� - C) <br /> ignature C v.4 s.� L �Xt \19 <br /> 1 23-0038 G'BANC/77o.+�s: <br /> I, At�L f�O�O/���'�I.F'tJ S�G7L-L l�. oda QBE �8/foc.`7 3� i'1�✓A,� <br /> 1 <br />