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CM 1Kul-,-4-1„L "CALIif UIVISIUN I APPLICATION FOR UN O ROUND TANK RETROFIT, TANK LINING, OR PIPING PAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE ROVAL DATE. DO NOT WRITE IN ANY SHADED AR . INDICATE PERMIT TYPE BELOW: _TANK REPAIR/RETROFIT TANK LINING _ PIPING REPAIR III IIIII IIII IIII]IIIIIIIIIIIII TANK 10 # 39- 'F`— / T 39-_ A 39-�� N 39- K 39- 39- 39- P ILII CIITITITT L APPROVED A - 36 7 -1775" r�-p70 d 72--40 93 /CLASS ,4q�+�[ size CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED % /"'(0y --afef a14 /j fz fft tIT1Tf1111 11rflTFI1TnTfffTriTTItTTityTiTT APPROVED WITH CONDITION(S) DISAPPROVED =E ATTACHMENT WITH CONDITIONS) /_ f N PLAN REVIEWERS NAME DATE lillllllilllllltllll lilli Ii7TTlliill Ill ! IIITIiiCtiii t1! 11 i11 lttliTiTt�if�ffftttitttt t t 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 CALIFO " �' I j�- / APPLICANT'S SIGNATURE: ��'�( TITLE &— h440G'j4l DATE I BILLING INFORMATION: Indicate the responsible party to be bitted 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 bittin ') g ,�by (signature and date below. v Name +tC5- /4_ Yew Z,57 Mailing Address 166 Al24„4, %Clc7f� ��, �73Cu.%yA/- (/ta, C1rZ06 1�A jC,�iA ii`9 ,� L✓� ® �� 1 Er" i.®f r J U L 0 81996 ENVIRONMENTAL HEALTH PERMIT / SERVICES EPA SITE # PROJECT CONTACT & TELEPHONE Al F A FACILITY NAME C� fr��//5 j�� PHONE # �f I ADDRESS G. Cf X -0, J'" 1 7T/� 4 G��/J �(�-• 9Sp� !� l L I CROSS STREET �7�D /� I / V- �-✓ T Y OWNER/OPERATOR /r creoI4,v PHONE # C 0 CONTRACTOR NAMEeJ 1"� 14 vi 5 oIv C;FT;ev LI � �� PHONE N T CONTRACTOR ADORES . O 30 i� / aS r. `{� Qsb� CA LIC # 6 as 3S7 f R A INSURER C -t5 /� /� WORK.COMP.# C T OTHER INFORMATION 0 R PHONE # PHONE # III IIIII IIII IIII]IIIIIIIIIIIII TANK 10 # 39- 'F`— / T 39-_ A 39-�� N 39- K 39- 39- 39- P ILII CIITITITT L APPROVED A - 36 7 -1775" r�-p70 d 72--40 93 /CLASS ,4q�+�[ size CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED % /"'(0y --afef a14 /j fz fft tIT1Tf1111 11rflTFI1TnTfffTriTTItTTityTiTT APPROVED WITH CONDITION(S) DISAPPROVED =E ATTACHMENT WITH CONDITIONS) /_ f N PLAN REVIEWERS NAME DATE lillllllilllllltllll lilli Ii7TTlliill Ill ! IIITIiiCtiii t1! 11 i11 lttliTiTt�if�ffftttitttt t t 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 CALIFO " �' I j�- / APPLICANT'S SIGNATURE: ��'�( TITLE &— h440G'j4l DATE I BILLING INFORMATION: Indicate the responsible party to be bitted 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 bittin ') g ,�by (signature and date below. v Name +tC5- /4_ Yew Z,57 Mailing Address 166 Al24„4, %Clc7f� ��, �73Cu.%yA/- (/ta, C1rZ06 1�A jC,�iA ii`9 ,� L✓� ® �� 1 Er" i.®f r J U L 0 81996 ENVIRONMENTAL HEALTH PERMIT / SERVICES