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r <br /> t ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT, OR ?I?ING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS =ROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. :tDICA13 TYPE BELOW%. <br /> TANK RETROFIT xPIPING REPAIR <br /> E?A SITE 4 PROJECT CONTACT & TELEPHONE t <br /> F ?AGILITY NAME I SONE 4 <br /> C i ADDRESS <br /> I f � <br /> L i CROSS STREET i <br /> T OWNER/OPERATOR i ?EONS ' I' <br /> Y <br /> i <br /> C I CONTRACTOR NAME TA2 , I ?HONE Ct ' <br /> 0 <br /> N i CONTRACTOR ADDRESS �) ! i CA LIC 4 �'9 i C-ASS .. i <br /> Y / <br /> R INSURER <br /> /�• yy °i i WCRK.CCMP.: <br /> i h. =a�L•Q• •w�- ® -- <br /> A <br /> C i OTHER INFORMATION <br /> ?HONE <br /> 0 i <br /> R ' i ?*HONE i <br /> -jlllllllllillllilllllllltlll111� <br /> TANK ZD <br /> ,i TAMC SIZE' � CHEMICALS STORED CLJERr.-YF'LY/?2:�OCSi'I ' ATE AST r`ISTALLED <br /> 1 39_ <br /> T 1 19-A 39- <br /> N i 39- <br /> K i 39- <br /> 39- <br /> 19- <br /> III[fill IIII IIIII if I Ifil IIIIIIIII <br /> 9-39-111111fill1ti1111111i11[tlilllllltl lllltlllll <br /> L 1 e APPROVED APPROVED WITH CONDITION(S) DZS?°PRCV=- <br /> A 1 (SEE ATTACHMENT WITH CONDITIONS) <br /> Y 1 ?LAN REVIEWERS N.1t4E DATE { <br /> -11?LAN REVIEWERS <br /> 1111111111111111111111illllt1111111111tliitllt111lllillllllltl111111111111 iiiiiiiit11111!lliittilillillillllll <br /> APPLICANT CRUST PERFORM ALL WORK 241 ACCORDANCE WITH SAN JOAQUiN COUNTY ORDINANCES, STX=3 :.•i'+tS. AND ZC'-.%S AND OF <br /> i <br /> STY JOAQUZN COUNTY PUBLIC ?=?.L.TFE SERVICr-S. OWNER OR :.ICE` 0 AGENT'S SIGNATSR- CST-r:s TIM 'CL:.ui��R'av 'I CsRT==-' THAT IN ` <br /> -sg PERFORMANCE OF = WORK FOR WHICH THIS ?ERMIT IS ISSUED, I SHALT. NOT EMPLOY ANY PERSON ZN SUCS A MANNER AS TO 3E CME <br /> SUBJECT. TO WORKER'S COMPENSATION LAWS OF CALIFORNIA., CONTRACTOR'S HIRING OR SUBCONTRACTING S:-`NA= CERTIFIES TEE FOL:AWING:i <br /> _ERTIFY HAT IN THE PERFORMANCE OF THE :CORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL -34PLOY ?r-+YSC`NS SLS�aC J +ORiOrR'S i <br /> COMPENSATION LAWS OF CALIFORNIA." i <br /> APPLICANT'S SIGNATJRE: <br /> TIT.: <br /> O <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PES--FID staff time e_r=ended beyond <br /> permit payment coverage per tank. If the party designated below is di =erent than the permit <br /> applicant, e.g. property owner, the party must acknowledge this responsibility nor the biding <br /> by signature and date below. <br /> Name address '��} 7 �,�+ phone number <br /> Signature <br /> EE 23-0038 <br /> l <br />