Laserfiche WebLink
.- i • ♦ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGR TANK RETROFIT, OR PIPING REPAIR PERMIT + O" T 2 2 2 i <br />O 0 1 <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PEP -MIT TYPE BELOW: <br />TANK RETROFIT _ PIPING REPAIR �':L_IEI <br />EPA SITE # PROJECT CONTACT & TELEPHONE # <br />F=ACILITY NAME /3e �� G17 3��// ' PHONE # zCJ C�7 7//,' <br />A <br />C ADDRESS Ale, e-,- �� -Ao / 7 <br />L CROSS STREET 6 -le 144' -r7 - <br />I I PHONE <br />T I OWNER/OPERATOR ` POO '7y <br />PHONE # <br />C I CONTRACTOR NAME <br />0 � ` I CA LIC# I CLASS <br />N I CONTRACTOR ADDRESS q r��/c t�.;, <br />T WORK.COMP.# <br />A ( INSURER 7G e <br />C I OTHER INFORMATION <br />17 I I PHONE # <br />0 <br />R I PHONE # <br />-- IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII TANK SIZE CH3MICALS STORED CURRENTLY/ PREVIOUSLY DATE UST INSTALLED <br />TANK ID # <br />139_ � �ZGc•Ci i�% C�c�cn� �/�/ec �' (�osu :�� i I <br />T I 39- <br />A I 39- i I <br />N I 39- <br />K I 39- <br />39- ' <br />19- <br />IIIIIII <br />-IIIIIIIIIlIIIIIII <br />-I 1111111111111111111111111 111111111111111111111 ����I��������I��IIII�I�I�II��I����III��II��II� <br />0 <br />I AP PROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />L 'n /� �//�',, S ATTACHM WITH CONDITIONS) � O <br />A I 11� 1 ��{IW ]CXX /SAA, DATE O <br />N I ?LAN REVIEWERS NAME <br />—IIIIIIIIIIIIIIIIIIIIIII I I IIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIII�����illllllllil I IIIIIIIII IIIIII III <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNT! ORDINANCES, STATE LAWS, AND RULES 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 SIGNATJPE CERTIFIES THE FOLLOWL`!G: <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 />CCMPENSATION LAWS OF CALIFORNIA.- <br />TITLE DATE <br />APPLICANT'S SIGNATURE: <br />ft � � Lfiir� <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 />Name �(Z;,; 11"la..rr, T- J-,,(-addressr-11/01- er, �S3��Phone number <br />Signature - <br />EH 23-0038 <br />►� �(:� <br />o <br />i <br />d -A- - - <br />