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'`^3 `ENVIRONMENTAL HEALTH DIVISION • .� (� ' <br /> APPLICATION FOR UNDERG2CUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT DEC 2 V 2000 <br /> THIS PERMIT EXPIRES 90 OATS FROM THE APPROVAL DATE- DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT j*VI&WENT HEALTH <br /> _TAMC REPAIR/RETROFIT -_TANK LINING IPl"PAIR PERMIT/SERVICES <br /> EPA SITE I JECT CONTACT b TELEPHONE .4 <br /> F FACILITY NAME p i-✓�/'- / T <br /> A PHONES <br /> C ADDRESS <br /> t tJ <br /> L CROSS STREET <br /> I <br /> T CWNER/OPERATOR <br /> T PHONE '1„U� p (+fin <br /> of / d of -9 yLj-z <br /> C CONTRACTOR NAME <br /> 0 C PHONE 9 0� /—/^ 3`2 <br /> N CONTRACTOR ADDRESS CA LIC S CUSS n (/J <br /> 2 INSURER ��/ C 6 -`Z <br /> um.CC1.fl 1 <br /> OTHER INFORMATION / <br /> I <br /> PHONE S <br /> unnaannaanaarrrtrr PHONE <br /> TANK ID S TANK SIZE <br /> 39- CHEMICALS STOREDCIMENTLT/PREVICUSLY DATE USTINSTALLED39- <br /> 39- 99 <br /> 39- <br /> It t 1 <br /> 39- <br /> 39- <br /> 39- <br /> tilt <br /> APPROVED PROVED WITH CCHOITICN(S) DISAPPROVED <br /> ' (SE T WITH CONDITIONS) <br /> ?LAN REviEIrERS NAME DATE <br /> anooarnnnaao a rotator uta uuurt tulruuortuuot a ntuuuauatt tort trotuuuutttu <br /> PPL ICANT MUST PERFORM ALL WORK IN ACCORCIANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> AM JCAOUIN COUNTY PUBLIC HEALTH SERVICES- OWNER OR LICENSED. AGENT'S SIGNATURE CEE TIFIES THE FOLLOWIMG_ MTIFTT OF <br /> HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL MOT EMPLOY R S TO FT THAT IN <br /> JBJECT TO WORXE.R'S COMP- SA ICN LAWS OF CALIFORNIA,' CONTRACTOR'S HIRING OR ANY SUBCONTRACTING <br /> [N SUCH A MANNER AS TO BEC@fE <br /> I CE3T(fY THAT IN THE PRF SUBCONTRACTING SIODIAT[AiE CERTIFIES THE FOLLOWING: <br /> �z--pF THE FOR VH[CN THIS PEZMIT IS ISSUED, I SHALL EMPLCY PERSONS W8JECTITO WORKER-S <br /> �+IPEHSAT[GV LAWS OF CA tFO I -tel <br /> 'Pt ICANT'S SIGNATURE: U /� TITLE4� <br /> NG INFORMATION- <br /> are the resoonsible party to be bitted for additional PHS-EMD staff time expended beyond permit <br /> designated beton is different than the permit applicant, a-g- r Payment -average per tank- [f the <br /> i I Ling by signature dale bet property oilier• the Party mst actsoutedge this responsibitity for <br /> &� �e <br /> ig Address !!ll5 9L3:o2�J� <br /> )ane Numbe <br /> vie .. <br /> 0033 'S <br />