Laserfiche WebLink
9-23-1998 3 : 14.PM FROM P.2 <br />EN'�RONMI+NTAL HEALT-i DIVISION <br />s <br />APPLICATION FOR UNDERGR.OVtM TANY RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT Z PIPES 90 DAY$ FkN4 THE APPROVAL DAT2. W NOT WRITP 19 ANY SHADaD AREAS.-INDICATF PERMIT TYPE SELCW: <br />_TANK xv,ROFI'r Pxpnn REp1AIR <br />SPA SITZ # PROTECT CONTACT d: TELEPHONE <br />F r4ciLIT'Y NAME o PHONE # r (E 7 f <br />4 _ .1 ® / <br />C A=RESS <br />L CROSS STVUEBT L, <br />I � 1� Li L� <br />j G➢Th ER/OP&ROTOR , ,� i PHONE # / 7 <br />1 CONTRACTOR NAME � PHONE # <br />N CO*^TRACTOR ADDRESS y .S, ? U 1 .I i CA LIC # i CLASS J457 4=11CI <br />�a <br />INSURtaX L J WORK. CC.btP . # , 1 <br />_ s® I <br />C I :`THBRNFO?XCPATION i <br />T <br />0 i i PHONE $ <br />i PHONE # <br />— <br />TANX rt!llrrrnlllnunrntl� <br />T.7AN& ID # TANK 5Y`CE J CF5MI;'ALS STCF.Eri 7=1TUX;'PR31aIOUSLY DATE UST I\S^.`.OLLFD <br />1 39 - `1 Z92, O® i_4&_z_4Qavm2 97- Z49 <br />T ! 19- �.._J� 000 <br />n 1 : ; 1 �1rJ 1 <br />N I j <br />--jtiilrlrlltauullti��`i tltrltlllllllrtrTrttrttrtnllntl� t ntltttallllt t ltrrttnlllllli n�tilr111illtllrlrtttlrttlllllrl <br />I APPROVED APPROVED WITH C QNDITICN ; S i nT.S.A.PPROv''ED i <br />A r (SEE ATTAC:.'MM11T WITH C01MI 11;1N5) <br />IRI PLA: FEVIE"IERS luxm PATE <br />—ittlltttllill11111111iflltltrttttllli� tttttllllllllll tttitalllllll�Il�`il atalttlillllllllllaalaatlllllllhlitlt U ltlllalltll <br />APPLIS1.I77 wi:;'r PFFFOR-M ALL WO" IN ACCORDANCE WITH SAN JOAQUIN COUVrY 0RDIXAI7CES, STATE LAW$, AND RULES ANn REGULATIONS Ji•' <br />R. PI JOA`UIN COUNTY PTIST,77 HEALTH SER"'VICE$. OWNER OR LICSNSk;D AGENT'S SIGNATIrAP `ERTIFIES Tiff FOTZ-OWING: eI C}:RT.TFY THAT IN <br />TAE P-ERFORMANCE OF TFR WORK FOR WHICH THIS PERMIT I ISSUED, I SXAL4 NOT EMPLOY iaPTY FE"NnN ICS SUCH A MA NER AS TO B::=7F.. <br />SUBJECT TO A'OR15R'$ WVPENSA.TION i.&v:.: OF CALIFORNIA." COi7RACTOR'S HIP -7.00 OR SUBCONTRACTING .+'GITATLTRE CER` XFIFS THE POLLO'AiNU: <br />^1 C-vRT;FY THAT IY THS PJlRFt^E OF THE WORK F(%R WHZCR THIS PER1w7T IS ISSUED, 1 fiHaUL EttPLCY PERSONA StJRiJECT TO WGrxER'S <br />CCX1P=N3;,TI3N Li-W:S OF CALIF,OR.TV A. 1' / , 11 <br />APFLI�k=S SIGNATURE: <br />BILLING IN'F'ORKATION: <br />TITLE S V 4A).4 DATE — <br />Indicate the responsible party to be billed for additional PHS-ERD staff time expended beyond <br />permit payment coverage per tank. If the party designated below is different than the permit <br />applicant, e.g. property odrner, the parte must acknowledge this responsibility for the billing <br />by signature and crate below. 7V ® r ® J <br />Name address 1 hone number 1 " <br />Sig_IaturE+ <br />SH `3-0038 <br />R <br />