Laserfiche WebLink
• . ENVIRONMEN:A.L HEALTH DIVISION <br /> APPLICATION FOR UNDERG TANK RETROFIT, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APP AL DATE. DO NOT WRITE IN ANY SHADED AREAS. KATE PERMIT TYPE BELOW: <br /> _VITANK RETROFIT _ PIPING REPAIR <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # <br /> ,�E� c'.O`f-egq4, <br /> A FACILITY NAME 7 `.0 . F. t LA5\i cpL, I,.A�\ PHONE # <br /> C A DRESS Y �[ � a'rE <br /> L CROSS STREET r� ) <br /> OWN' A'I S� PHONE # <br /> " <br /> ^ CONTRACTOR NAME <br /> arroQ, �� -UEv-833 <br /> N CONTRACTOR ADDRESS J C• `O c�>T� CA LIC q���C^l(L�� CLASS�I, <br /> T <br /> R INSURER& <br /> WORK.COMP. •��3-�� <br /> A <br /> C OTHER INFORMATION <br /> 0 PHONE # <br /> R <br /> PHONE # <br /> 11111111111111111111111111111111 <br /> TANK .D # TANK SIZE CHEMICALS STORED CDARENTLY/PREVIOUSLY DATE VST INSTALLED I <br /> 1 39- 1 4 . („!}ueu <br /> T I 39- I IASL Lu M i_ <br /> A I 39- <br /> N I 39- <br /> K I 39- <br /> 1 39- <br /> 39- <br /> —11111111111111111111111111111111111111111111111111 III111111111111111111111111111111111111111111111111111111111111111111111111 <br /> AP OVE _ APPRCS_D WITH CONDIT:ON(S) DISAPPROVED 1 <br /> A. "!ENT WITH CONDITIONS)?LAN REVIEWERS NAME DATE <br /> —11111111111111111111111111111'I1I1111111111111111�IIIIIIIIIIIIIIIIIIIII1111111111111111111111111 1 IIII IIII�IITilllllliill <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JCAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI S. OWNER OR LIG::SED AG'ENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY -HAT IN j <br /> THE PERFORMANCE OF THE WORK FOR WHICH IS PERMIT :E ISSuD, I SHALL NOT EMPLOY ANY PERSON /N SUCH A MANNER AS TO BECCME <br /> SUBJECT TO WORKER'S COMPENSATI FORMA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNAURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT ]N THE ERFO E OF HE WORK PO ICE CHIS ?EAMIT i5 ISSUED, I SHALL EMPLOY PERSONS SUBJEC? TO WORKER'S j <br /> COMPENSaT:ON LAWS OF1"I IA.`APPLICANTS SIGNATURE - TITLE• . DA^ !L%'�'�lcS' � <br /> I <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended 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 this responsibility for the billing <br /> by signature and date below. 3 <br /> Name r ss hone number <br /> F-'/(� - ((y <br /> SignaCur <br /> �C - <br /> S��AL <br /> EH 23-0038 <br /> J�a j2 n4-1-11 0 1 <br />