COMPLIANCE INFO 1998-2006 - Laserfiche WebLink

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hXVLKUNAtNIAL nCALIM u1V15WN APPLICATION FOR UNDER' 'IND TANK RETROFIT, TANK LINING, OR PIPING R' 'R PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. NDICATE PERMIT TYPE BELOW: _TANK REPAIR/RETROFIT _TANK LINING _ PIPING REPAIR EPA SITE 9 PROJECT CONTACT 8 TELEPHONE 9 F FACILITY NAME /. PHONE 9 z09. 936 . Z Z A C ADDRESS 1 L CROSS STREET I T OWNER/OPERATOR PHONE 9 Y C CONTRACTOR NAMEPHONE 9 �Q _ L 022i1 N CONTRACTOR ADDRESS 1-10 V0Q-�-�'!L/Y1Q/T �T T CA LIC 9 �y311 I CLASS . Ge„ T R INSURERI WORK.COMP.9 A C OTHER INFORMATION T 0 PHONE 9 R PHONE 9 TANK ID 9 TANK 512E CH �IICALS STORED CURRENTLY/ REV]WSLY DATE T IN T L 39- _ T 39- A 39- N 39- K 39- 39- 39- P L A R VED PPROVED WITH CONDITION(S) DISAPPROVED A (SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME DATE APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AG'ENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE. TITLE Dn0! /]/) Mbr DATE 1212-JO BILLING INFORMATION: Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the bil Ping by signature and date below. Name Mailing Address Day Phone Number ( ) Signature EH 23-0038 JIM 7