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i <br />.�a ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDER&D TANK RETROFIT, TANK LINING, OR PIPING R R PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FRC.+1 THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />_TANK REPAIR/RETROFIT STANK LINING ING REPAIR <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional PHS-E"HD staff time expended beyond permit payment coverage per tank. If the <br />oarty design ted below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br />the biMnpy signature and dat betow. // • / <br />12 <br />Nailing <br />EPA SITE 9 <br />PROJECT CONTACT & TELEPHONE 9 � •. <br />F <br />A <br />FACILITY NAME <br />PHONE it / •�%G� — <br />4 ✓ <br />C <br />I— <br />ADDRESS <br />L <br />I <br />CROSS STREET <br />T <br />OWNER/OPERATOR <br />PHONE 9 <br />Y <br />C <br />0 <br />CONTRACTOR NAME / <br />PHONE 9 <br />N <br />CONTRACTOR ADDRESS CA LIC S <br />CLASS <br />7 <br />R <br />A <br />INSURER I WORK.COMP. <br />C <br />OTHER INFORMATION <br />T <br />0 <br />PHONE <br />R <br />- <br />PHONE 4 <br />Ii11i11i111111I1i1111ilIlllllt <br />TANK ID TANK SIZE CHEMICALS STORED CURRENTLY/PREVICUSLY DATE UST INSTALLED <br />39 - <br />T <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P 1111 f111 IT <br />L APPROVED A ROVED W%TH CON IT Om( DISAPPROVED <br />_ _ <br />A EE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME 9/2 7 /7 <br />DATE <br />Iliiliiillillliiillliiilli 1I11Ililli lilt! I! ! ! 1 fl 1111111 It 1 1 Ii111i1llI1I111{iiiilillili1171 Iililiii i <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." CONTRACTCR'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 EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIF IA." <br />APPLICANT'S SIGNATURE: TITLE <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional PHS-E"HD staff time expended beyond permit payment coverage per tank. If the <br />oarty design ted below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br />the biMnpy signature and dat betow. // • / <br />12 <br />Nailing <br />