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:iii -25-1998 3:58PM FROM <br />' r a • <br />P. 3 <br />ENVIRONMENTAL HEALTH DIVISION <br />•'•AFPLICAT;ON FOR UNDERGROUND TANT. RZTROrXT, OR PIPING REPAIR. PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PE9N T TYPE BELOW: <br />1/ TANK a Rerne DSPINa REPAIR p <br />f EPA SITE # f PROJECT CONTACT S TELEPHONE # <br />F ( PACILITY NAME rb �,� f PHONE 1t /ZQG� <br />A ` J I <br />C ( ADDRESSCLQ <br />- <br />I --- <br />L f CROSS STREET { <br />I <br />T j OWNER/OPERATOR <br />Y I �'Y\ \ `ISO C'Xiati C ��O^ M { (. Z ✓ `/ O [ G.� <br />C I CONTRACTOR NAME Ct[r'O.r*�t.��d w Mtn.\ J• �QIYfL(MP��C� Cd. �hL I PKONS I� G?IG 1 L5 7 / O/ <br />O <br />N ( CONTRACTOR ADDRESS ZS „; s I CA LIC x SOZ37-% I CLAsSA edt D¢0 PAZ? <br />T 1 3 3 CA TL.. DIAL1 V C AG t / I <br />R I _NSUSTER �oo�tkA �CCII.N� GM�4• /Fel.t„`�Ga..� I WORK .COSP.f <br />A P" O <br />C { OTHER INFORMATION f I <br />T <br />0 I ( PHONE 9 <br />R <br />{ { PHONE $ <br />it11t11111111[tll[I1111 U Itllf *'- — <br />TAMC ID R ] TANX SIZE I CHEMICALS STORED CURRENEV <br />TLY/PRIOUSLYr { DATE UST INSTX.T.ED { <br />_ E <br />] 39- 1 { <br />T [ 39- <br />A 1 39-1'7,� J l'LI OOb f <br />N J 39- <br />R <br />i J { I I <br />39- <br />1 39- <br />1 39- <br />-illi!111I11111111tIII 111IIfill 11111111111111Ifii11 IfIII[I]I[I111]I[fill ] III] Hill ]!] fill] II1111fill fill I 111111111111[1111111! <br />L 1 AppR�VSD `r4,., APPROVED WITH CONDITIONS) DISAPPROVED <br />A [ SEE ATTAC194EwT WITH CONDITIONS) DATE <br />N ] PLAN REVIEWERS NAME <br />—filJll]Iiiltllilltil111it! Ii 1 111 Til[I11i11I11111111Etliltti1111]Iltllllilllilllfilili11t1lflllltitl111111 i111111llIllllll <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, APO RUL:S AND REGULATIONS OF { <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVLCFS. OWNER OR LICENSED AC,SNT'S SIGN&TURE CERTIFIES THE FOLLOWING: •I CERTIFY TFAT IN f <br />THE PERFORXANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL NGT' E►iPLOY ANY PSZtSON IN SUCH A . NNER AS TO HECC1� { <br />SML= TO wORKM, S COMPENSATION !„AWS OF CALIFORNIA.• CONTRACTOR`S HIRING OR SUBCONTRAC'ING SIGNATURE CSRTIFI=S THE ?OLLONING:( <br />"I CrRTIFY THAT IN THE PERFORMANCE OF THE WORK FOR MICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO JORKER'S { <br />COMPENSATION LAWS OF CALIFORNIA.' f <br />APPLICAN'T'S SIGNATURE: TITLE r' OATE R <br />I <br />ILLING <br />LOUN <br />T <br />ndicate the responsible party to be billed for additional PHS -EMD staff time <br />xpended beyond permit payment coverage per tank. If the party designated <br />elow is different than the permit applicant, e.g. property owner, the party <br />ust acknowledge this responsibility for the billing by signature and date <br />elow. <br />ame DESWIp6rovO address 07 a. we - 1 "hone number <br />ignature <br />H 23-0038 <br />1 <br />