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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGO TANK RETROFIT, TANK LINING, OR PIPING REIG PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FRC,M THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> STANK REPAIR/RETROFIT TANK LINING_ PIPING REPAIR <br /> EPA SITEI PROJECT CONTACT & TELEPHONE <br /> F FACILITY NAME PHONE <br /> A <br /> C ADDRESS <br /> I <br /> L CROSS STREET <br /> I <br /> T I OWNER/OPERATOR PHONE » <br /> Y <br /> C CONTRACTOR NAME PHONE » i <br /> 0 <br /> N CONTRACTOR ADDRESS CA LIC <br /> T CLASS <br /> INSURER / !� _ CAMP.» 29- <br /> Q!1-9-3"12 <br /> 3"12 '9 f <br /> C OTHER INFORMATION <br /> T <br /> D <br /> PHONE » <br /> A <br /> PHONE » <br /> Ilillltliltllllfltlil1111iittl <br /> 39- <br /> LANK IO » TANK SIZE CHEMICALS STORED CURRENTLY/P REV I CUSLY DATE UST INSTALLED <br /> A 39- _. <br /> N 39- <br /> K 39- <br /> 39- <br /> lilt <br /> P , <br /> L APPROV APPROVED WITH CONDITION(S) DISAPPROVED <br /> A EE ATTACH ENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> ftfllllllllttlftlliii !! 111 !il f tl 1111 !f 11 flit tt 1! 1 11 Itll tlll1111i11 tllll #!I 1 1 It tlfltlf <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> 1 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 CE.RRTIFIES 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 CALIFO 1t ob <br /> P <br /> j APPLICANT'S SIGNATURE: TITLE DATE <br /> i <br /> I <br /> ILLING INFORMATION: <br /> ndicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the <br /> arty des* ted below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br /> he biLC' g y signature and da below. <br />'ame <br />.aiL*ng Address / <br /> ay Phone N r ( a <br /> ignature <br /> 4 23-0038 " <br /> t ( l <br /> � t <br /> i <br />