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z <br /> "1"0• • ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION , <br /> APPLICATION FOR UNOERG%WN0 TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT V ' (" <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE 1N ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW- <br /> -TANK REPAIR/RETROFIT -_TANK LINING IPING REPAIR <br /> EPA SITE PROJECT CONTACT & TELEPHONE /y / <br /> F FACILITY NAME <br /> A (p PHONE '/ <br /> iADDRESS <br /> L CROSS STREET 7 lIJJ <br /> I <br /> T OLlNER/OPERATOR <br /> Y <br /> C CONTRACTOR NAME j <br /> P" /- 3 <br /> N CONTRACTOR AO RESS CA LIC Y <br /> T CUSS [JA, <br /> R INSURER <br /> WORK.CCIHP.X <br /> A 7 (y <br /> C OTHER IN FORMATION <br /> T <br /> 0 <br /> R I PHONE 3 . <br /> 11111111lIII111I111111111111I1 PxoNE s <br /> TANK IZE CHEMICALS STORED CURRENTLY/PREVICUSLY DATE UST INSTAL ED <br /> 1 39- <br /> A 39- <br /> N 39- <br /> 4 39- <br /> 39- <br /> 39- <br /> APPROVED APPROVED WITH CCNDITICN(S) DISAPPROVED <br /> t (SE4 ATTACHMENT WITH CONDITIONS) 7 <br /> 1 PLAN REVIEWERS NAME / J(f1/I�f./,/.4 (� �(y�/ DATE .,(-1 / <br /> -7 <br /> II1111111111111I111111111�1�;tti,jinuu,iii,i ll� 11111111111111111111 II lilllllllllllliillll!111111111111t11111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOACUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN PERFORN COUNTY PUBLIC HEALTH HIO'SERCES. OWNER 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 i0 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 WCRKER'S <br /> COMPENSATION LAWS OF CALIF NIA." <br /> APPLICANT'S SIGNATURE: ///yh,�i� - - T <br /> LING INFORMATION: - <br /> icate the responsible parry to be billed for additional PNS-EHD staff time ex <br /> ty designated below is different than the pemit applicant, e.g. property � beyond pOust payment coverage per tank. [f the <br /> bil Cin P Pe ry owner, the party must acknowledge this responsibitiry for <br /> g by signature and date helow. <br /> e <br /> ting Address ,qr <br /> Phone Number ) GCJ <br /> urure - - <br /> c�r,uF. �YG9 5� 4aS30IAd <br /> Hl <br /> l`d3W -l`d1N:l l��NpalnN� <br /> Ccd�/e%stC�. G 0002 :v0 833 , <br />