COMPLIANCE INFO_1998-2004 - Laserfiche WebLink

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ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: STANK R£PAIR/RETROFIT _TANK LIMING ,PIPING REPAIR APPLICANT ?LUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAM JOAOUIN COUNTY PUBLIC HEALTH SEERVICEES. 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 WCRKER'S COMPENSATION LAWS OF CALIFO IA." -T 4 ,' APPLICANT'S SIGNATURE: /TITL.. � LING INFORMATION:. q icate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank- If the ty designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for biLk,ing,by,signature,jand date below. PI 3-008 EPA SITE 9 I PROJECT CONTACT g TELEPHONE 9 ! h > e// { / l� 4 /) (/ 4 FACILITY NAME PHONE AOORESS 37 / b LC/ _ CROSS STREET f OWNER/OPERATOR PHONE 9 CONTRACTOR NAME '' /7� /) .. PHONE ^ r I CONTRACTOR A00 SS CA LIC S CLASS I INSURER r % / OTHER INFORMATION I PHONE S itiiitlt11tI11IIlllltttlilttlt PHONE it TANK ID TANK SIZE CHEMICALS STORED CURRENTLY/PEVICUSLY DATE UST INSTALLED 39- / 39- dCu n 39- w f f 39- 39- 39- 39 - APPROVED APPROVED WITH CONDITIONCS) DISAPPROVED SEE ATTACHMENT WITH CONDITIONS) PLAN REVIEWERS NAME DATE illillit11t111tItlilltttittttiitttlttltltttittit 1tt111i tttttttlitlil116181i I1 'uta tat n ttaaaaaaaaaaaaaaaaraaaa u „ a uIa APPLICANT ?LUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAM JOAOUIN COUNTY PUBLIC HEALTH SEERVICEES. 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 WCRKER'S COMPENSATION LAWS OF CALIFO IA." -T 4 ,' APPLICANT'S SIGNATURE: /TITL.. � LING INFORMATION:. q icate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank- If the ty designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for biLk,ing,by,signature,jand date below. PI 3-008