Laserfiche WebLink
APPLICATION FOR UNDERGROUND TANK RETROf IT, TANK Li NIRG, OR PIPING REPAIR PERMIT <br /> Y THIS PERMIT EXPIRES 90 DAYS FROM THE•OVAL DATE. DO NOT WRITE IN ANY SHAPED AREAOO(CATS PERMIT TYPE BELOW- <br /> O: TANK REPAIR/RETROFIT TANK LINING —L—PIPIMG REPAIR <br /> EPA SITE P PR04ect CONTACT L TELEPROCE a <br /> F ' FACILITY MAME <br /> C ADDRESS <br /> (�u� Ma Cati C s <br /> L CROSS STREET k D-J. t4J <br /> I <br /> T OWNER/OPERATOR �1 . PHONE >• :: <br /> YJ40 �A (.r <br /> ��- L.3 - "7CJo- <br /> C CONTRACTOR NAI¢ PHONE /,.�. Lt l�5 ,�r'. r• <br /> 0 <br /> R CONTRACTOR ADDRESS 'Gv o u LICr 3� 3 O ttASS <br /> RINSURER WORK.COMO-0 <br /> A (.JCP <br /> C r OTHER INFORMATION <br /> i <br /> 0I PHONE 0 <br /> R <br /> PRUE 4 <br /> llff1111111111111111111flfllll <br /> TANK IO 0 - L' TARN SI2E CHEMICALS STORED CLJRRENTLY/PREVICUSLY DATE LIST INSTALLED <br /> 39• - / " <br /> Y 39- <br /> A 39• (� <br /> N 39- <br /> K 39- <br /> 30• --- <br /> 39- <br /> 111) <br /> P � <br /> L I�APPROVED WITH CONOITION(S) r,;: OISAP?ROVEO <br /> ,(SEE ATTACHMENT WltA CONDITIONS) <br /> H PLAN REVIEWERS'HAw WIT <br /> illllitltllilllillll tllli <br /> APPLICANT MUST PEOMM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY 001U(CES, STAt`E LA t XAtm'd Li 'I(1tQ 1(!'Ipp-At•(�NS Of <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.% OWNER OR LICENSED AGENTIS SICXATLIRE CEQTIftEs TNE'fCL NCt',k,;+!I vCLrRTtf?':.tfulT Itl <br /> THE PERFORMANCE Of.lk WORK FOR WHICRZ4918; ERMIT IS ISSUED, I SHALL NOT EMPLOY. 'Ad iC ktak , <br /> SUBJECT TO WORKERF11:00WENSATfON LAWS dP'CALIFORNIA-" CONTRACTOR'S HIRItlG OR 'S M1`RACYYN� TA A' `kt Rifft 3 31.f �PDLIOvtaG: <br /> 'I CERTIFY THAT IN THE PERFORMANCE OE'THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 �$?ni$e6vRl8Ct-TQ•"ik�tl(ii-as j.. <br /> COMPENSATION LAWS OF'CALIf NIA."- <br /> , { / <br /> -17 <br /> APPLICANTS SIGNATUREt TITLE �ID�'I <br /> Blll(NG INFORMATION->;•.,� <br /> ,c - <br /> Indicatc the respenitbl l�piirty to be b(lted for abditicnat PNS-EMO staff tle* experdeC beyond permit payment goverige per tenk. If thr <br /> party designated bettiit .4,different that{ the permit epplieant, e.g, property oseTer, the party must acknowtedge this responsibility fa <br /> she b(L(•ing by sigr4tuklkrd date below. / <br /> Name <br /> Ha i t i ng Address. -` F. - <br /> Day Phone Number (y ,y- �..3C My-� /✓�C.�w1A�O 1fixn <br /> Signature <br /> EH 23.0038 �• ''r U"` °-� y �` �• ` PUBLIC HEALTH SERVICES <br /> Poswt"brand fa ran smittal memo 7671 mor ages f3 $AN JOAQI IIN COUNTY <br /> :73 /Iru r-Pim / la <br /> O° fadnJLS G� ° S PAMEI,A S. VIOLETT, R.F.H.S. <br /> S.n;or Registered F.nwironmemsl Health $prcirhki <br /> Dept. Phone P <br /> Faz0 pr 3 Faxr li.,.irnnmrnlal <br /> p 7 I Ilfalth N inion WJS iJ $:c In;�nn Ctre� <br /> 36£:.(111$ Pf) Mom jPR. <br /> I ;� 12"9) 364.01 18 <br />