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y APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br /> TAS PERMIT EXPIRES 90 DAYS FROM THE OVAL DATE. DO NOT WRITE IN ANY SHADED A INDICATE PERMIT TYPE BELOW: <br /> TANK REPAIR/RETROFIT TANK LINING PIPING REPAIR <br /> EPA SITE 9 PROJECT CONTACT & TELEPHONE 9 <br /> F FACILITY NAME PHONE # <br /> A <br /> C ADDRESS <br /> I <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE 9 <br /> Y Z0 a �?W <br /> C CONTRACTOR NAME PHONE <br /> 0 <br /> N CONTRACTOR ADDRESS Cr9 CA LIC CLASS <br /> Tzyzp t� Z_Zfj,6,0 <br /> R INSURER WCRK.CCMP.9 <br /> A <br /> C OTHER INFORMATION <br /> T <br /> 0 PHONE # <br /> R <br /> PHONE 9 <br /> I111111111t1111lDII11lII111111 <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVICUSLY DATE UST INSTALLED <br /> 39- / /AJC ,),La,,,� <br /> T 39- K <br /> A 39- 7� <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> 1111 111'�T�TTT I I T1T <br /> P <br /> L APPROVED _ APPROVED WITH CONDITION(S) DISAPPROVED <br /> A ( EE ATT 4MENT WITH CONDITIONS) -9 A?- <br /> N PLAN REVIEWERS NAME DATE <br /> 1I11iIlitlillti111111111 Iltl Illl i 1111 t11 11i11111111 1111 I 1111 tlltll 1! lllJi 11111it111111i1111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATICNS OF <br /> SAN JCAOUIN 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 SECCME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTCR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE 8 ®' -14-1,40— DATE <br /> BILLING INFORMATICN: <br /> Indicate the responsible party to be bitted for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the <br /> party designated beton is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br /> the bitting by signature and date below. <br /> Name zn <br /> Mai t ing Address 1-112- L1 `5 2— <br /> Day Phone NLmcer (W? ) /p 126 <br /> Signature <br /> EH 23-0O33 <br /> e <br /> 1 <br /> � � 1 <br /> 1 � �. <br />