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ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNOER1 ID TANK RETROFIT, TANK LINING, OR PIPING R, t PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: _TANK REPAIR/RETROFIT TANK LINING 7'C Pipiur. RFPAIR BILLING INFORMATION: Indicate the responsible party to be billed for additional PNS-EHO 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 date below. Name %�7�'L�2�lC_J ( Qom.//i"�i�2 Gz ✓'� �Z Mailing Address S .5 / M Day Phone Number ( !'C/5_ 3 L 2— 3 3 F_� ` Signature EH 23-0038 1 EPA SITE » PROJECT CONTACT & TELEPHONE #' F FACILITY NAME 7j 6 PHONE # A ! ADDRESS I e c e421 L CROSS STREET T Y OWNER/OPERATOR �"! __[I f / /J�✓C7- �p)� PHONE #/` �crV !/ �v ) =� OC 5 CONTRACTOR NAME ,Q /! , ✓ PHONE it N CONTRACTOR ADDRESS/,�''//�/�✓ �� CA LIC# CLASS R INSURER /� s1!«� s GlGr WORK.COMP.# 60(f %'�� `�2 Z>,� A C OTHER INFORMATION T 0N p( 0 PHONE # R 11111111111lIllllll11111111111 TANK ID # 39 - PHONE # TANK SIZE CHEMICALS STORED RENTLYREVIOUSLY DATE UST INSTALLED T 39- d A 39- � N 39- K 39- 9 -39- 39- 39- 39- P P L A PROV APPROVED WITH CONDITION(S) DISAPPROVED A ( EE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NA Illllllilllilililllll 1l lllil DATE I I 1 Ili! 1111 1111 !1!111 1111111 111 I Il 1111111111111111 I it Iillllllillllllll APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAOUIN COUNTY PUBLIC HEALTH 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 THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WCRKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: C-w`YJi�: dG TITLE /l�fs DATE —� / BILLING INFORMATION: Indicate the responsible party to be billed for additional PNS-EHO 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 date below. Name %�7�'L�2�lC_J ( Qom.//i"�i�2 Gz ✓'� �Z Mailing Address S .5 / M Day Phone Number ( !'C/5_ 3 L 2— 3 3 F_� ` Signature EH 23-0038 1