Laserfiche WebLink
ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDER, 7D TANK RETROFIT, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _TANK RETROFIT L PIPING REPAIR <br /> EPA SITE # C � Qa al 1 PROJECT CONTACT S TELEPHONE <br /> F FACILITY NAME „'APHONE 2,3 IS-7-317,9 <br /> C I ADDRESS 7y�/' /40 O <br /> � 1 Cy <br /> CROSS STREET /1��.►�NLE2 7 g <br /> T I OWNER/OPERATOR/-, SALAZTi' I PHONE # <br /> CI CONTRACTOR NAME t G S E QV 1 L�E..S I PHONE #uZ5-9 `f <br /> qq. -178 O <br /> 0 ( <br /> TI CONTRACTOR ADDRESSS✓2'7 N. ha k £w - F�-E.b.�o I LIC # 704 q?Z- I C:asS <br /> R I INSURER �TA-T1E rlJN_!"/ I WORK.COMP.# /�(va L/ 6 /R <br /> A <br /> C I OTHER INFORMATION <br /> 0 I <br /> PHONE # <br /> R <br /> PHONE # <br /> TANK <br /> �IIIIIIIIIIIIIIIIIIIIIIiIII <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INST.y.LED <br /> T 139- 1 I I <br /> A I 39- <br /> N 1 39- <br /> K I 39- <br /> 39- <br /> 39- <br /> ?]I <br /> 9- <br /> 39-]I 111111111111111111111IIIIIIIIIIIIIIIIIIIIIIIIIIII alllll�(�/�JJ�II 111111 IIIIIIIIIIIIIIIIIIIIIII111111111111111111111111111, <br /> L 1 PROVED APITH ITIO DISAPPROVED M <br /> A r (SEEACHM WITH CONDITIONS) <br /> N I PLAN REVIEWERS NAME hi/ 4V7 c' K <br /> —IIIIIIIIIII111111111Ili 111111111111n111 in in I ii I I I I I I I I I I ItTillIIIIIIIIIIII[IIIIIIIII[IIIIIII IN II IIII�IIII1111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUiN COUNTY ORDINANCES, STAT LAWS, AND RULES AND REGULATIONS Oe- <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 STORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A :BANNER 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��^�-�` �- //y TITLE J£2y 6'f DAT 7 <br /> 3ILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond <br /> permit payment coverage per tank. If the party designated below is different than the permit <br /> applicant, e.g. property owner, the party must acknowledge this responsibility for the billing <br /> by signature and date below. <br /> Name address phone number <br /> Signature <br /> EH 23-0038 <br /> 1 <br />