COMPLIANCE INFO_1985-1996 - Laserfiche WebLink

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ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDE*ND TANK RETROFIT, TANK LINING, OR PIPING ROR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: '----TANK REPAIR/RETROFIT _TANK LINING 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 bi l ling by signature and date below. Name Ste/ ' i �-ti% S 4•4 , P---) 7- - ti :�_, Mailing Address ".c)*� �C-� / d Day Phone Number (Z -U Signature.G ~—'E/� 11 D SHfYtcJ N -0038 1 EPA SITE # PROJECT CONTACT & TELEPHONE # F A FACILITY NAME //PHONE 1, )A It � � / # 3--7(7(-- �� ? C I y ADDRESS 7a <-> Z� �oS� [ :'�I L CROSS STREET U 7 I Y OWNER/OPERATOR E #�� C#�j C 0'� CONTRACTOR NAME PHONE N CONTRACTOR ADDRESS'? n CA LIC # s , P -Z CLASS 14 h1A 7 104/ T R INSURER nAJi 4r �!�✓c�74�'i WORK.COMP.# A C OTHER INFORMATION T 0x q PHONE #fig R PHONE #------�_ 111111111111111111111111111111 TANK ID # TANK SIZE CHEMICALS TOR 0 C RENTLY/PREVIOUSLY DATE UST INSTALLED 39- /l) /� -4-2 ' 3iUl, ��i � T 39- / L� K "� ! "" W . L A 39- N 39- K 39- 39- 39- 1111 P LPPROVED APPROVED WITH CONDITION(S) DISAPPROVED A (SE ArTTACHMEN� T SALIN-CONDITIONS) J N PLAN REVIEWERS NAME / DATE [ III III I111111IIIII III 1111 1111111111 IIIIn II 111111 I IIIIIIII 11111 I II 111111111 111111111111111111 I I 1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH 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 COMPENSATION LAWS OF CALIFORNIA." � I)eA-) Pr, ' �'Y" C 1 `C �y� 7� APPLICANT TITLE DATE S SIGNATURE: �C .:�i 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 bi l ling by signature and date below. Name Ste/ ' i �-ti% S 4•4 , P---) 7- - ti :�_, Mailing Address ".c)*� �C-� / d Day Phone Number (Z -U Signature.G ~—'E/� 11 D SHfYtcJ N -0038 1