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I ENVIRONMENTAL HEALTH DIVISION y - APPLICATION FOR UNDEOND TANK RETROFIT, TANK LINING, OR PIPINGIR PERMIT •THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREA.INDICATE PERMIT TYPE BELOW: _TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR BILLING INFCRMATICN: Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the bitting by signature and date below. Name Mailing Addr Day Phone Number ( ) Signature 40 EH 23-0038 r' - '�C�v►�-�-�' . 1 EPA SITE » PROJECT CONTACT & TELEPHONE ;* F A FACILITY NAME �' - PHONE,'` C I ADDRESS L I CROSS STREET T OWNER/OPERATOR PHONE # i C CONTRACTOR NAMEPHONE I ? "j _/a`' 0 N CONTRACTOR ADDRESS 1 �� = CA LIC # �..CLASS .' i R A INSURE`L- )s~ WORK.COMP.* _ r/ C OTHER INFORMATION PHONE LT 111111111111111111111 PHONE ! l l l } 1111 TANK IO TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- OjIL T 39- A 39- N 39- K 39- 39- 39- ! 111 P / L APPROVED 1APPROVED WITH CONDITION(S) DISAPPROVED A y � N PLAN SllE' ATTACHME T WITH CONDITIONS)% REVIEWERS NAME ( LXt _�; 1111111111111111111111111111111 IilJl lIII Il111111T�11 1111111 I1 111 DATE Q oG IIITf Iilllll1111111111 Iilll 11111 111lllilll APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLCWING• "I CERTIFY THAT IN THE PERFORMANCE OF THE 'WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTCR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S CCMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: TITLE d 4ij TE a � BILLING INFCRMATICN: Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the bitting by signature and date below. Name Mailing Addr Day Phone Number ( ) Signature 40 EH 23-0038 r' - '�C�v►�-�-�' . 1