COMPLIANCE INFO_1999-2009 - Laserfiche WebLink

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:..: liv V:•::.:lei M., :1Li�., .:Y .—._�_va• * •APPLICATION FOR UNDER* TANK RETROFIT, OR PIPING REPAIR PERMIT • THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: _TANK RETROFIT PIPING REPAIR BILLING 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. Name address phone number Signature EH 23-0038 1` C , � ►1,1., L � �C1� ^"-� � � � � (�hi6 � 46 Jl cJtJ JA EPA SITE # PROJECT CONTACT & TELEPHONE # F A FACILITY NAME �7jy ' PHONE # C ADDRESS I L Z CROSS STREET � l4 TI Y OWNER/OPERATOR ( PHONE # Cel r� 3�Y �I? 3 C I CONTRACTOR NAME PHONE # 0 C N CONTRACTOR ADDRESS LIC # CLASS T R INSURER WORK.COMP.# A C I OTHER INFORMATION T O R PHONE # PHONE # -1 1111111111111111111111111111111 TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- 1 � T 39 - A I 39- N 1 39- K I 39- 9- 39- ' 39- 39- 39- 111111111111 �11�111111111111fillI�� L I APPROVED _APPROVED WITH CONDITION DISAPPROVED 1 E ATTA 1 WITH CONDITIONS) Al N PLAN REVIEWERS NAME_t � DATE —111111111111111111111111 1111 1111111 1�1111111111111�111111111111111111111111111111111111111111 111111111111111111 1111111 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE KITH 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 WHICH THIS 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 OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S I COMPENSATION LAWS OF CALggIF�O,RNIA." i APPLICANT'S SIGNATURE: TITLE _��'"u-'�'--��- DATE^ BILLING 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. Name address phone number Signature EH 23-0038 1` C , � ►1,1., L � �C1� ^"-� � � � � (�hi6 � 46 Jl cJtJ JA