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ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FORORGROUND TANK RETROFIT, OR PIPING REPAIR P& <br />THIS PERMIT EXPIRES 90 DAYS PROM THE APPROVAL DATE, NOT ITS IN ANY SHADED MEAS, INDICATE PERMIT TYPE BELOW: <br />TANK RETROPI P PTNG REPAIR' <br />SPA SITE ,N PROJECT CONTACT 6 TELEPHONE N <br />a FACILITY NAME PHONE <br />PHONE N9�/v <br />A K77' <br />64P ­eit <br />C I ADDRESS /�'}® J^j <br />L( CROSS STREETv vv <br />I LT�c.xu J <br />T 0 PERATOR PHONE N ` <br />Y ( I r <br />s <br />CONTRACTOR NAM869 �PHONE N .�✓T_�/b� <br />0 L�CJ"7 s <br />N CONTRACTOR ADDRESS Q©f.� I CALICr�yq�p/Q� CLASSCt <br />R INSURER )(], Y� _ r _ate? WORK. COMP, p <br />C OTHER INFORMATION <br />T ((� <br />0 I PHONE N <br />R <br />�lIIIII U IIIIIIIIIIIIIIIIIIIIII l PHONE M i <br />TANK ID N � �,, TANK SIZE CHEM CALS STORED CURRENTLY/PREVTOUSLY DATE UST rNSTAI,[,FO <br />39- CEF�b -�- Soot—_ <br />T 39- <br />A 39- <br />N <br />9-N 39- I — <br />K 39- <br />39- <br />P <br />9 -39-P <br />L APPROVED APPROVED WITH OND TON(S) DISAPPROVED <br />A SE ATT IT C ITIONS) <br />N PLAN REVIEWERS NAME DATE <br />11111 M III <br />11111111111111 M11111 <br />PLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, ANDR S 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 LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />•I CERTIFY THAT IN THE PSRF0 C8 OF WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF �10 A. <br />APPLICANT'S SICNATVRB: TITLE � ft! rA6E/LDATE <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond <br />permit payment coverage per tank. If the party designated below is different than the permit <br />applicant, e.g, property owner, the party must acknowledge this responsibility for the billing <br />by signature and date below. <br />amel�t'C laddresg Sl"hone. number,06I-y6ff- -(163% <br />Signatur <br />EH 23-0038 <br />1 <br />