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IF <br />A <br />C <br />I <br />L <br />(I <br />T <br />Y <br />T <br />A <br />` N <br />K <br />P <br />L <br />A <br />N <br />ENVIRONMENTAL HEALTH DIVISION <br />i <br />j APPLICATION FOR UNDERGROU1NK RETROFIT, TANK LINING, OR PIPING REPAIMIT <br />4S PERMIT EXPIRES 90 DAYS FROM THE ARAtd AL D N07 WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />TANK REPA RETROFIT TANK LINING PIPING REPAIR <br />EPA SITE # <br />FACILITY NAME <br />P` e <br />ADDRESS <br />S t, A <br />CROSS STREET 4C, k iNr <br />CONTRACTOR NAME <br />CONTRACTOR ADDRESS <br />INSURER <br />& TELEPHONE # <br />PHONE # <br />+ PHONE <br />PHONE # <br />CA LIC # - CLASS/- <br />. WORK.COMP.#S�i"��, <br />OTHER INFORMATION ` <br />PHONE # <br />PHONE # <br />Illi 11111 till lllllilt!lttlltll <br />TANK ID # TAN IZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />39- <br />39- <br />39- <br />39- <br />39- <br />39- <br />1I1 <br />APPROVED APPROVED WITH CONDITIONS) _ DISAPPROVED <br />// / (SEE ATTACHMENT WITH CONDITIONS) <br />PLAN REVIEWERS NAME / �'� 1/ '/`"'�' DATE j3 �I <br />111 11111111111111111iniT>TiiTt I Hill 1111 111111fil I 11111111 <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 ,�CALIFOR IA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PE FO AN <br />__....E WO H THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA."�1 <br />APPLICANT'S SIGNATURE: �TITLEi'F_ g DATE <br />(BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional PNS-EHD staff time expended beyond permit payment coverage per tank. If the <br />party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br />the bitting by signature and date below. <br />Name _ <br />rl>; } <br />Mailing Address Tc© -'Cd>cv--'- 0' A �Szo/ <br />Day Phone Number ( L <br />Signature / <br />EH 23-0038 2 -- <br />6&,�f# ti Fr-� tt�V <br />&(M Ce,- j <br />►/G+ 117 ti c� e <br />