Laserfiche WebLink
` ENVIRONMENTAL HEALTH DIVISION C TSS <br /> APPLICATION FOR UNDERGO TANK RETROFIT, TANK LINING, OR PIPING REI• PERMIT <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 B - PROJECT CONTACT & TELEPHONE N (' K <br /> F FACILITY NAMEPHONE If a�-5 <br /> A <br /> ADDRESS <br /> I 6Hiqba)1,rz1j <br /> Q!j ? <br /> - L4600 w C7 <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR -6" od PH NE R _ ll <br /> Y <br /> C CONTRACTOR NAME tfr/j/1' �S PHONE 0 &337 <br /> 0 v t <br /> N CONTRACTOR ADDRESS CA LIC.x CLASS <br /> TC�S f- <br /> R INSURER `r� WORK.COMP.X - _ /�Gt _ r'1 <br /> A V I 1 <br /> C OTHER INFORMATION <br /> T <br /> 0 PHONE X <br /> R <br /> 111111111111111111111111111111 PHONE x <br /> TANK ID : TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- 1 OS— O D O S4/ 8� Ac.�'aoe. Gal,/iuu.. �f <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P 1111 <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A "�CC 6�I^`EE ATTACHMENT WITH CONDITIONS) 6 9 7 <br /> N PLAN REVIEWERS NAME 4Z�L% �/(•E✓Gr!•r DATE <br /> 1111111111111111111111111 T IIIIIII� IIIIIiIfITIiI II�fTITrIIIII I1 I i I 111111111111111 I III 1 I1I1IiII <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: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 1S ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." 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 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." R <br /> APPLICANT'S SIGNATURE: IN% TITLE DATE _ <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-EHD 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 billing by signature and date below. <br /> Name \ IMMI <br /> Mailing Address E� � .� \{� �P_ u IU) I <br /> Day Phone Number ( P�&I <br /> signature <br /> EH 23-0038 <br /> 1 <br />