COMPLIANCE INFO_1991-2000 - Laserfiche WebLink

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ENVIRONMENTAL HEALTH DIVISION If n % APPLICATION FOR UNDERGamwD TANK RETROFIT, TANK LINING, OR PIPING R PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPRJVAL DATE_ DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: _TANK REPAI 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 tan',;. If the party designated below is different than the permit applicant, e.g, property owner, the party must acknowledge this responsi'-,ility for rhe billing by signature and date below. ,ailing A ay Phone ignature .il 23-0038 _t a I I EPA SITE # PROJECT CONTACT & TELEPHONE # > AGILITY NAME PHONE # C ADDRESS I L I CROSS STREET T OWNER/OPER OR ��....yy p PHONE #l��7:e Y PHONE # 7,. C CONTRACTOR 9AME---"— N T CONTRACTOR ADDRESS ' `r CA LIC #� tl� CLASS1 / R A INSURER ® /ma j y - WORK. C OTHER INFORMATION 6 T 0 R PHONE # IIIIIIIIlI11111111I11111111111 PHONE # TANK ID # 39- TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INS",aLLED 3 39- A 9- N 39- K 39- 39- 39- P IIII RiTTITilf1TTT L A APPROVED APPROVED WITH CONDITION(S) DISAPPROVED }' 'LAN REVIEWERS NAME (SEE ATTACHMENT WITH CONDITIONS) 111111111111111111 I 11111 II lil IIII I1 DATE VIII Ill 11 IffMM111111 111111111 I illlli�(il 1111 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH THE PERFORMANCE OF THE WORK FOR SERVICES. OWNER OR LICENSED WHICH THIS AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN 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 "I CERTIFY THAT IN THE PERFO A E WORK FOR WHICH THIS OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: PERMIT IS ISSUED, I SHALL COMPENSATION LAWS OF CALIFORNI .' EMPLOY PERSONS SUBJECT TO WORKER'S APPLICANT'S v SIGNATURE: TITLE f DATE BILLING INFORMATION: Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tan',;. If the party designated below is different than the permit applicant, e.g, property owner, the party must acknowledge this responsi'-,ility for rhe billing by signature and date below. ,ailing A ay Phone ignature .il 23-0038 _t a I