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- ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS ?ROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE ?ERMIT TYPE 3ELOW- <br /> _TANK RETROFIT PIPING REPAIR <br /> RPA SITE $ PROJECT CONTACT & TELEPHONE az�a.C-'�w,�l 77 <br /> �� _�;M <br /> aFACILITY NAME CAA 2,y r ONA S—p,—r-,,,� q- Z-] PHONE #�1-5) o t1 2- 0-0 Z- T <br /> C ADDRESS 1 W JA l n'�►1 F-�O 1� I <br /> L I CROSS STREET <br /> T 1 OWNER/OPERATOR of 1 PH NE p <br /> C ( CONTRACTOR NAME �' Sr� ?HONE - Q <br /> I i <br /> 0 <br /> N 1 CONTRACTOR ADDRESS fl �S '1_!'1 CA ,ic -� 2 z3(,o CLASS <br /> T n <br /> P'o sok o� Lo , .iC`t A�, MA a- ! <br /> R I INSURER I/V1 c V e. Pio�K v-s I WORK.comp. 5 P I 1 (e 1e 6 O A <br /> A <br /> C OTHER INFORMATION 1 <br /> 0 I I PHONE <br /> 2 <br /> i PHONE <br /> ANK <br /> -111111111111 : i1111111111U <br /> TANK iD $ TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY � DATE US':' --NSTALLa"D � <br /> 1 39- - S 1 I0 Q o-0 i �M�- o( - OA<-r 1 1.- 10- 9'7 1 <br /> T I 39- �_T I I <br /> A l 39- <br /> N 1 39- I I <br /> K 1 39- <br /> i 39- I I I <br /> 7ATPP <br /> APPRRJVEDROVED WITH CONDITIONS) DISAPPROVEDA i , r- TACI�IEn WITH CONDITIONS) 7 <br /> N 1 ?LAN REVIEWERS NAME '( Z`h't�� � DATE <br /> --lilllllillliiltlllllilll I Itl iltillitlllliiilllllllliliitilllitittillillllllititlitllllitlllll 1 III 11111111111ilillil <br /> AP?*.:CANT MUST PERFORM ALL WORK :N ACCORDANCE WITH SAN ,:OAQUIN COUNTY ORDI-GUNCES, STATE LAWS, AND RU^.ZC AND REGULATIONS OF <br /> 3?N .:OAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGE".7T'S SIGNATURE CERTIFIES THE FOLLOWING: ^I C--RT::Y -HAT IN j <br /> THE ?ERFORMANCE OF THE WORK FOR WHICH THIS ?ERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO 3---COME <br /> SL"3.:EC7 TO WORKER'S COMPENSATIgnLAWS OF CALIFORNIA.- CONTRACTOR'S HIR**-NG OR SUBCONTRACTING SIGNx=RE C RTI?IES T:- FOLLOWING:! <br /> :SRTIFY THAT IN THE PERFO -E OF THE WORK'FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S j <br /> COMPENSATION LAWS OF CAL:FO IA. <br /> APPLICANT'S SIGNATURE OATS <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 b ow. (� <br /> 140� <br /> Name je. .I—( e. (( ��ad ess C6�,;�,, �►� �1 phone numbed'-'o I `�3�-0 <br /> Sianature <br /> EH 23-0038 <br /> i <br />