Laserfiche WebLink
ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDER NO TANK RETROFIT, TANK LINING, OR PIPING RL'T7CIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHAD AREAS. INDICATE PERMIT TYPE BELOW: <br /> _TAN'K/REPAIR/RETROFIT _TANK LINING Y PIPING REPA}R ge,4r,0F71j <br /> EPA SITE # 2O D PROJECT CONTACT 8 TELEPHONE # CHFiSTcF4 eGhlr_l=-f T- 9110 635-2.444- <br /> F <br /> 35.2444F FACILITY NAME IINOGAL Aly +It F $ PHONE # <br /> A 209- 952- 167 <br /> C ADDRESS 410-7 PACIFIC AVC <br /> L CROSS STREET <br /> 1 MARCH LAt4G <br /> T OWNER/OPERATOR PHONE # <br /> Y JAMES J. WCAKTHY 209— 952-767(, <br /> C CONTRACTOR NAME " En L PHONE <br /> R 0 U ! O <br /> 3 N CONTRACTOR ADDRESS CA LIC # CLASS <br /> ( T <br /> CZ R INSURER WORK.COMP.# <br /> a A <br /> p C OTHER INFORMATION <br /> T <br /> 0 <br /> 4 PNONE # <br /> R <br /> 111111 IIIIIIIIIIIIIIIIIIIIIIII PHONE # <br /> T ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST VJS LLED <br /> 39- HAL 87 ocrAt4p LNLEADED GA401dN6 ��U T:' <br /> T 39- — 121000 GAL 92 <br /> A 39- <br /> OCTNADD <br /> AtAQ tlLEE4A40LItA9 Jr <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> IIII <br /> P <br /> L qPROVEDWITH CONDITIONS) DISAPPROVED <br /> A S A A ENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE v <br /> IIIIIIIIIIIIIIIIIIIIIIII �I 1111111 I II I II I I IIIIIIIII III III I IIIIIIIIIIIIIII�IIIIIIIIII IIII IIIII I <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: "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 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." <br /> APPLICANT'S SIGNATURE: '�-�"L- `�V V"" ..�1 '" ` — l TITLE DATE <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PNS-END 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 bitting by signature and date below. <br /> Name UNOCAL CC-RPORAT101­� A1 MIKE H6G6.t4Poor,\ <br /> Mailing Address 7(a BROADWAY 6ACr?AMaNTC> GA 95S1a <br /> Day Phone Number ( 91G ) 556 - 7(g14 <br /> Signature \�ILF�j c-_ <br /> PAYMENT <br /> EH 23-0038 RECEIVEn <br /> MAY 1 7 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SFRa ;; <br /> ENVIRONMENTAL HEALTH DIV;, <br /> 1 <br /> 0 <br />