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APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE Al JAL DATE. DO NOT WRITE IN ANY SHADED ARE/,r !NDICATE PERMIT TYPE BELOW: <br /> TANKK./REPA /RETROF _TANK LINING _ PIPINGR PAIR <br /> EPA SITE # PROJECT CONTACT 8 TELEPHONE At - — <br /> FACILITY NAME PHONE <br /> C ADDRESS !i <br /> i I <br /> L CROSS STREET C <br /> 1 <br /> OWN ERATOR PHONE # <br /> CONTRACTOR NAME PHONE # ` <br /> 0 \J, <br /> N CONTRACTOR ADDRESS C: ,N _ CA LIC # CLASSG6 UNA� <br /> I R INSURER �(�jr[�N(, >f'b'L WORK.CCMP.#SOrf <br /> � <br /> A <br /> C OTHER INFORMATION <br /> T <br /> O PHONE # <br /> PHONE # <br /> 111111111111111111111111111111 <br /> 39- 0 <br /> R TAS 512 ?� CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> T 39- <br /> A 39- — <br /> .1 39- <br /> < 39- <br /> 1 39 <br /> 1111 <br /> ? APPROVED APPROVED WITH CONDITICN(S) DISAPPROVED <br /> q ,Al ATTACC M,E.NNT�WIT•H CONDITIONS) <br /> PLAN REVIEWERS NAME �n � ��% /1� SiG./GJ.J DATE alk- <br /> 1111111111111111111IIIiI 1111 111 111111 1jjjLfljWjjjjjjjrjT111 I itIfffflTri111111111 1 11111 111111 IIIIIIiI <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JCAOUIN COUNTY PUBLIC HEAL NER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br /> SHE PERFORMANCE OF THE WOR OR WHICH IS PERM --IS-ISSUED, I SHALL NOT EMPLOY ANY PERSON 1N SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S CCMPE SATIC LAWS F CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT 14 THE P ORMA CE OF HE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS.OF CA !A <br /> i Q <br /> APPLICANT'S SIGNATURE: TITLE �AI'G�-S DATE <br /> r <br /> O,tM S C }i L U 1 J7VI B eY1/✓� �' <br /> 3ILLING INF�ICN: C4/% � �, 0v1 f-s.�i(� pl. a l- <br /> �;tr,�v1�2 �L.Q.u.> Yht7�Lil.�T7't.t/�^�- •'!- �.Qc�(.7j(J( fz-G(/ <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 billing by signature and date below. <br /> flame {E L� l_CE/FQf.f<E . <br /> Nailing Address `� /E'`� �r-'�^�^"�f`Cr-'-^ 0'3 <br /> Cay Phone Number (Z(i�j <br /> d` <br /> Signature <br /> :*Note, I.v or K a� ���� ye <br /> H 23-003 S f n n Tj „ -_I� t, <br /> (� S QC7ii fQv l hf¢itio �j'I <br /> V SpcHc <br /> Q1 RS V��u <br /> P. <br /> PHSn �.�0� W to �` � , <br />