COMPLIANCE INFO_1991-2000 - Laserfiche WebLink

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ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGRCIPTANK RETROFIT, TANK LINING, OR PIPING REPOPERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: _TANK REPA /RETROFIT TANK LINING atatur. DFDeiD JBILLING 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 date below. ,r^ Name �tC. :— ?P� �.-®6� ! P� . _r;sAP _ Mailing A Day Phone Signature IEN 238 1 A SITE # � PROJECT CONTACT & TELEPHONE #,_` A ACILITY NAME PHONE # SZ r - ZA C ADDRESS t-- L CROSS STREET T OWNER/OPE ATOR PHONE #®g Y 9r500,7--7W-zC:) C CONTRACTOR NAME PHONE # —� 0 N T CONTRACTOR ADDRESS !fie �` ` CA LIC #�30 I C� CLASS j 7 R INSURER A. 1) o4eWORK.COMP.#� A C OTHER INFORMATION T 0 PHONE # R 111111111111111111111111111111 PHONE # TANK ID # 39- TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED T 39- A 9- N 39- K 39- 39- 39- P 11 111TT1TfTfffi L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED A (SEE ATTACHMENT WITH CONDITIONS) !' AN REVIEWERS NAME 111111111111111111 IDATE 1111 II III III Il II111 Il 11 I I I I I I I I 11111111111111111 flI APPLICANT MUST PERFORM ALL WORK 11111 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 WHIM—TV! PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATI N LAWS 0 -CAL IA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PER RMA E OF T WORK FOR HICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFS N , APPLICANT'S SIGNATURE: TITLE DATE �J JBILLING 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 date below. ,r^ Name �tC. :— ?P� �.-®6� ! P� . _r;sAP _ Mailing A Day Phone Signature IEN 238 1