Laserfiche WebLink
ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGMANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE_ DO NOT WRITE IN ANY SHADED AREAS <br />_TANK RETROFIT PIPING REPAIR <br />40 <br />INDICATE PERMIT TYPE BELOW: <br />:r <br />EPA SITE # PROJECT CONTACT & TELEPHONE # —17 <br />�/; <br />F FACILITY NAM PHONE #1.1 c <br />C ( ADDRESS <br />I <br />L I CROSS STREET <br />I <br />22k <br />T I OWNER/ E, /) n i i PHONE # <br />Y I )/ l/. <br />C CONTRACTOR NAME <br />PHONE��- <br />0 X51 ," <br />N ( CONTRACTOR ADDRESS i y��/ I CA LIC 1 I CLASS 9 / `% �J <br />T f l <br />R I INSURER I WORK.COMP_# <br />A <br />C I OTHER INFORMATION I I <br />T <br />0 I I PHONE # <br />R <br />PHONE # <br />TANK <br />--illlfliifilillllllllilfill <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />i 39- I I I <br />T i 39- <br />A l 39- I I I <br />N I 39- <br />K I 39- I I I <br />i 39- I I I I <br />f 39- 1 I I I <br />— 111111111111111111111111111 Iilll Iliiliillllllllilillilllllllllllllllillllllllllllllllliillllllllllllllllliliiililillillllll <br />P <br />L I AP VED APPROVED WITH CONDITION(S) DISAPPROVED <br />A i ATTACHI�IT WITH CONDITIONS) J( 1 <br />-1111111( 1111111111111 1 111 II N PLAN REVIEWERS NAME 11111IIIIIIIi111111i11111111111111111111111111111111111!11 Ill! lif(JI 1111111111111111 <br />DATE <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF 1 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWI.NG: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES TH= FOLLOWING:( <br />"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHTLL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNI J%J//,�//JJ <br />APPLICANT'S SIGNATURE: TITLE 6&l.-�''V/(/(�(//ei,(.II 115"1�3 / I!, <br />BILLING 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 signaturexAd date below. <br />Na dre"41,�CPt) ne numberz6y <br />Signature <br />EH 23-0038 <br />0 1 0 <br />