Laserfiche WebLink
i" T- T-34 FF: I 11 :Z0 .T F.I--'Ei 1 1-4 S 0F TF-r_I=.1'IF-IG Ihll_. O'y�8�n8G. � r . F31 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Nn h <br /> APPLICATION FOR UNDER O TANK RETROFIT, TANK LINING, OR PIPING R PERMIT <br /> TH <br /> VVT EXPIRES 40 DAYS FROM THE APPROVAL DATE. DO NOT VRITL IN ANY SHADED AREAS, INDICATE PERMIT TYPE BELOW: <br /> '" TAMC REPAIR/RETROFIT TANK LINING PIPING REPAIR <br /> EPA SITE 4 PROJECT CONTACT & TELEPHONC <br /> F fAC1LITY NAME PHONE X �K <br /> A 1 <br /> C ADDRESS <br /> 1 <br /> L CROSS STREET IL <br /> 1 <br /> T NE PERATO PHONE 0 <br /> Y <br /> tk <br /> C EraNTRfICTnn II0 22" "'360 `T <br /> a w` <br /> N CONTRACTOR ADORESSOZ-¢ !u� F arc �c CA LIC $ ' _ /` CLASSe <br /> T <br /> R INSURER. WORK.COMP. Cj L&t <br /> A <br /> C OTHER INFORMATION <br /> T <br /> 0 PHONE <br /> R <br /> PHONE <br /> llllllllll[11111t! 11IIIIlr[tr <br /> TANK ID TANK SIZE CHE141 S STORED CURRENTLY/PREVIOUSLY DATE UST INS`ALLEp <br /> 39 <br /> T 39- <br /> A 39- <br /> N 34- <br /> K 39- <br /> 39- <br /> 39- <br /> L <br /> 9- <br /> 34-39- <br /> L T APPROID APPROVED WITH CONDITION(S) DISAPPROVED <br /> A / (SEF ATTACHMENT WITH CONDTTTnN-S) <br /> N PLAN REVIEWERS NAME �iZ �u�' - -- y` <br /> DATE U'�- <br /> [nrlltl[Ilullllllr I ! t[ i t !11![( dart[ l t r �[ <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQqN' utNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSEDAGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY TP%T IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED; 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER 0 TO 9ECOMx, <br /> SUBJECT TO WORKER'S COMPENSATION LAMS QF CALIFORNIA," COFj�R/1CTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOI.LCUING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WH1CN� S PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT To WORKE,11S <br /> COMPENSATION LAWS Of CALIFNI <br /> APPLICANT'S SIGNATU E,.. TITLE LC DATE <br /> BILLING INFCRMATIONt <br /> Indicate the responsible party to be billed for additienat PHS-EHD staff time experded beyond permfz payment coverage per t.ik, If the <br /> party designated below is different than the permit applicant, e.g. property owner, the party must ecknculedge this responsibfllty for <br /> the billing by signature and date below. <br /> Name -- rA R 0 Q) I IBJ Is ccs n3 / <br /> Mailing AddressO.l 00 `7-+t 'R.O.-&-4 . <br /> Day Rhona r ) ,� <br /> L <br /> Signature r a �.;^� ��r c --.•�-�� - <br /> � <br /> �� �Y^0L �k'71�� ,�p++- ,.;1�"fI�`k-V� +-e-`�,^"-,�.y"fc^'-'� ��_,�J r+..'�,` GfJr7� �v G r`✓. <br /> EH 23-0038ytbG.,:. e�PJ1f�Cfr r Uv�4 4�e7 (f / a <br /> 0 S4 <br /> ce <br /> C- <br />