Laserfiche WebLink
6 ENVIRCNMENTAL :.HEALT?i DIVISION <br /> APPLICATION FOR UNDERGROUND TANK 'RETROFIT, OR PIPING REPAIR .?ERM:: <br /> •^FIS ?ERMIT EXPIRES 96 DAYS PROM THE APPROVAL DATE. 170 NOT WRITE IN ANY SHADED AREAS- INDICATE P5R."SIT TYPE ?FLOW; <br /> _TANTO ;=CFIT A PIPING REPAIR <br /> SPA SITED PROJECT CONTACT � TELEPHONE x .4 im—P" -wLlr Zy I <br /> CaDLI �y <br /> ' FAC:LITY NAME 1,1 �"�. PONE _ <br /> C i ADDRESS � <br /> I � <br /> L f R455 STREET baPx Ctf <br /> r <br /> T I OWNERIOPERA OR ti - I PHONE '4 <br /> T'RC( CARS � a leG`fii.�c. CC) - j 5awc- I <br /> C I =ONTRACTOR NAME j ?HONE 4 <br /> 4 i <br /> N I --ONTRAC:'OR -aDOPLE.SS I CA -:C x j CLASS <br /> T <br /> R I _NSURER I WORK.COMP.x <br /> A <br /> c <br /> 0 G j PHaxE f j <br /> s I Pa4NE # I <br /> --illullilllllllllllflllilllllli _ <br /> TANK ID 3 :':iNi{ moi_.. EMIC.�:.,5 .�_On=i .Z::dTL'f:?4. 7A72 ,S :NS"'ALLED <br /> ! 19- <br /> T 139- I I I <br /> A 139- I I I <br /> .1 <br /> K I 39-- <br /> ;9- <br /> 39- <br /> ?Jill[ <br /> 9-39-JI111 <br /> L t APPROVEZ APPROVED WI-71t CONDITT_ON(SI DISAPPROVED <br /> I !SEE =_4LC:-74` -NT NITH CONDITIONS) <br /> `—f111�Illitll!!!!IlIIIIIIIl1111111IIIlIIIIIItlllllllltlllll111111111111iI11111[IiIIIIIIIIIIIIIIIIfliittttltitlllll!!I[lllllltl <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCI WITH SAN yOAQUIN COUNTY ORDINAaNCES, 3 3T-z LAWS, AND RULZS AND REGULATIONS OF <br /> SAN ;OAQUIN COUNTY PUBLIC HEALTH SZRVICS. OWNER OR EIC'--NSED AG--rr'S SIGNA:JRE =3'=-_T_ES THE FOL:-OWING: "I =_-y 7HAT IN I <br /> 711 PERFORMANC-- 'OF :1E WORK 'OR -AHICY "-"TS PERMIT --S :SSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH .A MANNER AS _"0 3ECOME I <br /> SUBJECT TO WORKZR'S COMPENSAT:ON LAWS OF CALIFORNIA." CONTRACTOR'S 'TIRING OR SUBCONT?ACTING 3IG.W1.:,RE CERT-=S -.qE FOLLOWING-i <br /> '•' =SRTIFY THAT IN THE PERFORMANCE OF Tax. WORK FOR WHICH THIS PERMIT IS ISSUED, 13FALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> CCMPENSATION LAWS OF CALIFORNIA." I <br /> APP'-_CaNT'S SIGNATURE: TITLE. DATE <br /> 3ILLING INFO pMI�I"T_ON: <br /> Indicate the responsible party to be billed for additional ?FSS-MM staff time ezMended beyond <br /> permit payment coverage per tank. if the party designated below is different than the permit <br /> applicant, e.g. property owner, the party must acknowledge _his responsibility for the billing <br /> by signature and date below. <br /> Name address phone number <br /> Signature <br /> H 23-0038 <br /> 1 <br />