COMPLIANCE INFO_1991-2000 - Laserfiche WebLink

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ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDESND TANK RETROFIT, TANK LINING, OR PIPING I* R PERMIT NIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: +TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR 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 bill -Ing by signature and date below. Name CRISP PETROLEUM ENVIRONMENTAL Mailing Address P.O. BOX 30847 STOCKTON Day Phone Number (209 ) 931-1828 FAX 465-3806 Signature '11 (; 'I"? k' ) _ �"" / cz,, ^ e- -71y e(l��i� N_�'� V ( l� I�.N�J Sy Y-^14 EH 23 -0038G - l'_ ✓ l/.+3 rte Grp Y EPA SITE # PROJECT CONTACT $ TELEPHONE # F FACILITY NAME DDRW—MFW—SHARPE FACILITY PHONE # A C ADDRESS BLDG S-41 LATHROP CA 95331-5108 I L CROSS STREET I T OWNER/OPERATOR PHONE # Y C CONTRACTOR NAME CRISP PETROLEUM & ENVIRONMENTAL PHONE # 209 931-1828 0 N CONTRACTOR ADDRESS P.O. BOX 30487 STOCKTON C ACA LIC ON FILE CLASSA T R INSURER ON WORK.COMP.# ON FILE A C OTHER INFORMATION T O PHONE # R PHONE # TANJ-,ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39 '/ _ 2 Z L i dl -Zi T 39 _ A 39- N 39- K 39- 39- 39- iTT�ATiTTTTTTTf �TTITiTTffTTfffiTTTT LA APP ED APPROVED WITH CONDITION(S) _ DISAPPROVED _ (S ATTACHMENT WI TIONS) PLAN REVIEWERS NAME - DATE - IIIIIIIIillllllllllllli!I I I I I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA." ',a �`f APPLICANT'S SIGNATURE: '! / 4%`L `=•- ( .< �, TITLE MANAGER DATE 6/17/94 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 bill -Ing by signature and date below. Name CRISP PETROLEUM ENVIRONMENTAL Mailing Address P.O. BOX 30847 STOCKTON Day Phone Number (209 ) 931-1828 FAX 465-3806 Signature '11 (; 'I"? k' ) _ �"" / cz,, ^ e- -71y e(l��i� N_�'� V ( l� I�.N�J Sy Y-^14 EH 23 -0038G - l'_ ✓ l/.+3 rte Grp Y