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MIAOMMUTAL HeALT11 61VIS1ON <br />APPLICATION FOR UNOERGR TANK RETROFIT, TANK LINING, OR PIPING REP PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE PROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />TANK REP R PROFIT TANK LINING _ PIPING REPAIR <br />EPA SITE # T CONTACT & TELEPfIONE # <br />A AGILITY NAME PHONE <br />I <br />C ADDRESS <br />L CROSS STREET 1 <br />I <br />T OWNER/OPERATOR PHONE # <br />Y G <br />C CONTRACTOR NAME o —Z 992 <br />PHONE # <br />0 I <br />N CONTRACTOR ADDRESS �CAIC # CLASS <br />T ' <br />R INSURER WORK.COMP.#D�h/ <br />C OTHERINFORMATION <br />T <br />0 <br />R <br />PHONE # <br />ttlliltlltltliltll111l111ltltl PHONE # <br />39 - <br />TANK 10 # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTILLED <br />T 39- <br />A 9- <br />N 39- <br />K 39- <br />39- <br />39- <br />tT <br />P [fill <br />L APPROVED _ APPROVED WITH CONDITION(S) DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITIONS) <br />P' 'LAN REVIEWERS NAME DATE , <br />IIIIIItItlllllltll III II II 11 1 I IIlII III 111 I 111111 IM -11111111 1 1 11 11 Ff <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <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 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 THE FOLLOWING:, <br />"I CERTIFY THAT IN THE;.PERF ANCE OF T17 WORK .FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIF RNI <br />n <br />APPLICANT'S SIGNATURE: TITLE DATE % <br />ILLING INFORMATION: <br />7dicate the responsible party to be billed for additional PHS-EHO staff time expended beyond permit payment coverage per tanV. If the <br />arty designated below is different than the permit applicant, e.g- property owner, the party must acknowledge this responsibility for <br />ie bitting by signature and date below. <br />ame �+�p <br />ailing Address y <br />ay Phone Number <br />ignature <br />23-0038 <br />1 <br />d <br />a <br />n <br />a <br />a <br />0 <br />a <br />