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May 03 01 02:26P Govt. Bldgs. (209)468-4757 P.2 <br />is <br />ENVTRONM-V7AL HEALTH DIVISION 0 6V q0 f3 q I <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PUP141T EXPIRRS go DAYS FROM THE APPROVAL DATE. Do War WRITS IN Ayy SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />TANK RETROFIT PIPING REPAIR <br />R <br />A <br />C <br />7 <br />0 <br />it <br />7 <br />A <br />N <br />F <br />EPA ST -1- # PROJECT CONTACT & TELEPHONE OM <br />L— *-T— <br />FACILITY NAME PHONE -4 < 1-11 PAL..,, # 2d9, <br />> <br />ADDRESS t7 <br />CROSS STREr*T <br />K <br />PHONE # <br />0', PERAT jit - <br />!h! 11 OL't I <br />7 PHONE #,76q- qc el's 7---,,-,c-o- NAME <br />CA �:C #SIOC/0,57 <br />CONTRACTOR ADDRES <br />RK.COMP.# <br />ONE I <br />TANK ID # TANK SIZE w^H4ZCAL5 STORM) CURRMaTLY/PREVIOUSLY DATE UST INSTALLED <br />39- A <br />39- <br />39- V q "t 65, �6 A <br />39- <br />V <br />39- <br />ilt!! { 111i{ii{titi ttt itt i{{{ t 1 {t{t!ltitlliii ittltlttlitl tt 1{11!{11 till 1111 !ii !lltlit! 1 <br />39- <br />APP <br />APPRCVBD WITH CONDITIONS; DISAPPROVED <br />D <br />BE ATTZACH14ENT WITH CONDITIONSI <br />PLAN REVIEWERS HAMS DATE <br />APPLICANT 4UST PERFORM ALL WORK IN ACCORDANCE WITH SAN :QAQUIN COUNT ORDINANCES, STATE LAWS, AM RULES AND RECULAT:ONS OF <br />SAN JOAQTJjN COUNTY PUBLIC ARALTH SERVICES. OWNER OR -:--SNSED AGF-XT1S S.IGW.-.;RE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF '"HE WORK FOR WHICH THIS PERMIT IS :---SVTD. I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUB. -ECT TO WORKER'S COMPENSATION L&S OF CALIFORNIA." --=TRACIOR1 S HIR;XG OR SUBCONTRAC-iNG SIGNATURE CERTZFIES THE FOLLCWLNG: <br />"I CERTIFY THAT IN -IR111 kCC-zB IF THE WORK FOR WH-�f_-N* THIS PERMIT ZS ISSUED, I SHALL IRMPLOY PERSONS SUBJECT TO WORKER'S <br />!70MPENSATION LAWS OF <br />APPLICANT'S SIGXA7URE: <br />TITLE ATS5�- �rq-o <br />pende eyond <br />Indicate the responsible party to be billed for additional PHS-EHD staff time ex d b <br />permit payment coverage per tank. Tf t1ie party designated below is different than the permit <br />applig cant, e.g. property owner, the party must acknowledge this responsibility for the billin <br />by signature and date'below. <br />ER 23-0038 <br />