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e � a <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UROERGRCUND TANK RETROFIT, TANK LINING, ON PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 CAYS FROM THE AP22CVAL DATE. 00 40T WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _TANK REPAIR/RETROFIT _TANK LINING _- PIPING REPAIR <br /> EPA SITE P 1 ' I, PROJECt CONTACT S TELEPHONE N /y!l•1G• j, h S G <br /> F FACILITY NAME "7r 1/ T zTSurlAJoIGAu� PHONE ZoyyZ —[1'172 . <br /> A <br /> [ ADDRESS .'. <br /> I <br /> L cools STREET <br /> 1 PHONE M �y <br /> T OWNER/OPERATOR 0/ <br /> C CONTRACTOR NAME �gp J`NU lr120AJmcN-G.t9 C ►xONE (C��6 (o 52-s"}-a'� <br /> 0 CA LIC N CLASS <br /> N CONTRACTOR ADORES$ 3��0 [>'7�J <br /> t wORK-CCMP.S <br /> R INSURER <br /> A <br /> c OTHER INFORMATION <br /> T PHONE N <br /> 0 <br /> R PHONE e <br /> {{{{{{{{{Iii {{{{{{{{{{{{ <br /> TANNKK 10 N TANK 4[gE CHEMICALS STOWED CURRENTLTlPREVIOUSLY DATE UST INSTALLED i <br /> 39- <br /> t 39- <br /> A 39- <br /> 4 39- <br /> 39- <br /> [fill <br /> 9•39•{{{{ <br /> .- APPROVED PPROVEO wITK CONDITION(S) _ DISAPPROVED <br /> q ` S ATTACHMENT WITH CONDITIONS) (] <br /> A PLAN REVIEWERS NAME NMIMPROATE 9 " 2��2 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> $AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY ?KAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MARINES AS TO BECOME <br /> SLSJECT TO 4AKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES TME FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE VOK FOR WHICH THIS PERMIT 14 ISSUED, I SMALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." Lj— <br /> APPLICANT-4 SIGNATURE: Y 1LE//++ DATE <br /> BILLING INFORMATION; <br /> Indicate the responsible party to be Of l led for additional PH$•EPD staff time 0XPended beyond Permit payment Coverage per tank. If the <br /> Darty designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this reapensibitity for <br /> the bilking by signetwre and data below. <br /> Nene <br /> n ' ) <br /> Mailing Address,ID S �A1i•> ! •G__,„ Mtn �f) �747`�y <br /> i <br /> Gay Phone Number C 1 ) — <br /> Signatwre n <br /> EH 23.0038 � /I1 41V M/0 NO vrN xad 4 <br /> C N N evavd <br /> Str 2 g 1995 <br /> wad aA <br /> ENVIRONMENTAL HEALT Z 4 10 4 6/ ` aro [g[ eloN KIEd.4-120d <br /> PERMIT/SERVICES <br /> I 'd EC : ST 96/61 /60 0bj <br />