Laserfiche WebLink
1 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ` APPLICATION FOR UND&NO TANK RETROFIT, TANK LINING, OR PIPING&IR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> TANK REPAIR/RETROFIT _TANK LINING 4 <br /> PIPING REPAIR <br /> EPA SITE # PROJECT CONTACT 8 TELEPHON # I <br /> F FACILITY NAME � - PHONE # C- Z 4,,j <br /> A <br /> C ADDRESS P , <br /> I <br /> L CROSS STREET NaMOACR <br /> T OWNER/OPERATOR I PH E # _ <br /> Y ,iywar Tvlc. cqi L'- <br /> C CONTRACTOR NAME I 1 PHONE # r2cS <br /> 0 <br /> N CONTRACTOR ADDRESS CA LIC # CLASS <br /> T <br /> R INSURER WORK.COMP.# <br /> A <br /> C OTHER INFORMATION <br /> T <br /> 0 PHONE # <br /> R <br /> PHONE # <br /> TANK IO # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> 3 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> MTMTffffmffffP <br /> L yAPPROVED APPROVED WITH CONOITION(S) DISAPPROVED <br /> A �, Q P I S ATTACHMENT WITH CONDITIONS) <br /> DATE <br /> N PLAN REVIEWERS NAME L//-�-�1+ 4 / <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: n•-CJ T11` '�E l.y"E=4"�(VIL•tyc-- DATE II 1'T <br /> BILLING INFORMATION: \J <br /> Indicate the responsible party to be billed for additional PHS-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 bit Ling by signature and date below. <br /> Name <br /> Mailing Address_ �7 ( 1 VI IV� kF + <br /> Day Phone Number <br /> Signature <br /> EH 23-0038 <br /> 1 <br />