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5-26-1998 1:d8PM FRC � P-2 <br />r, 1 ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND TANK RETROFII, TANK LINING, OR PIPING REPAIR PERMIT <br />IS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />���t�-aPAY-� �m <br />TIINK RfiIR/RE7ROF17 TANK LINING _ PIPING REPAIR <br />EPA SITE Y PROJECT CONTACT t TELEPHONE d <br />ci`7 w2)49 S <br />F FACILITY NAME <br />uA A Ly-\ I l L PHONE U 5 . �, 71/ <br />K � .. <br />C ADDRESSG n\ Do4 <br />t i <br />L CROSS STREET <br />I <br />TOWNER/OPERATOR PMO # <br />53 S -spm <br />C CONTRACTOR NAME_ ` T r C PHONE 2 <br />0 <br />N CONTRACTOR ADDRESS a _ CA LIC X i1 CLASSI <br />T �T <br />R INSURER vwx.=w.N Lsct7 5�, Q <br />A <br />C OTHER INFORMATION <br />T <br />O PHONE 2 <br />R <br />PHONE # <br />11li111l111IlI1Ii11111l11I1Ii1 <br />TANK ID A TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />54- <br />T 39- I _ <br />x 39- 1 iT . tST.I <br />39- <br />39- <br />1111fill 1111111111111111 1111111 frffmTm <br />P <br />L APPR - APPROM WITH CONDITIONCS) DISAPPROVED <br />SSPE ATTACHMENT WITH CONDITIONS) <br />A -T Q <br />N PLAN REVIEWERS NAME A, x-, DATE <br />fill I111]111111itIII f fill11 ! f 11 I ! f II II llllli ! !HII IIIIIII III I I IIII <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNT? ORDINANCES, STATE LAWS, AND RULES AND REGULAT;ONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICU$ED AGi;aiT'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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMKOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA/J." <br />APPLICANT'S SIGNATURE: U �e .'� J,�� TITLE DATE <br />BILLING INFORMATION! <br />Indicate the responsible party to be bitted for additional PMS -EAR) staff time expende0 beyatfd permit payment coverage per tank. If the <br />party designated beteu is different than the permit applicant, e.g. property owner, the party must acknowledge this respensibitity for <br />the biLLing by signature and date betow. <br />Name_ �G��_ as <br />Mailing Address U <br />Oay Phone Number ( ) <br />Signature_ _ <br />/. 7 -w -f- I -a- jvf- fcic I - <br />.Cm 23-0038 Z _ L Leri Ce, v_ v_0 �- �-e (a- cam- <br />o L,,-&-1 h�.��L//./�.�L/./J'1 /Y} G� <br />