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.' ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGR, . TANK RETROFIT, OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: TANK RETROFIT PIPING REPAIR EPA SITE # " PROJECT NTACT & EPHONE F FACILITY NAME PHONE# oe+ _,�3^/n A / / w I ADDRESS I / L I CROSS STREET I Y i OWNER/OPERATOR D i PHONE vl0-9'6J ^ A C CONTRACTOR NAME e. PHONE # 2o 9 0 N I CONTRACTOR ADDRESS M� CA LSC # :17� I CLASS A/C /0 H/-Z R I INSURER r I // I f VWORK.COMP.#D'y,0 A v v ✓✓✓ C I OTHER INFORMATION I I T 0 I PHONE # I R PHONE # TANK I "IDD """""I TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED ## 39- I I T 39- I A t 39- N II 39- K ' 39- I ' 39- L ' APPRO PROVED WITH CONDITIONS) DISAPPROVED1'1 A ' (SEE W ONDITIONS) � DATE N PLAN REVIEWERS NAME Nuc A.4 1) APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC �IEALTH SERVICES. OWNER OR LICENSED AGENT'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 71=_ FOLLOWING:I "I CERTIFY THAT IN THE PERF CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLQY PERS S SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIF RNI I APPLICANT'S SIGNATURE: TITLE 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 billing by signature and ate below. Nam G � (iC/I one numberd�E Signature EH 23-0038 `'— ©