COMPLIANCE INFO_1996-2004 - Laserfiche WebLink

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APPLICATION FOR UNDERGRCUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT �— TH1 PERMIT EXPIRES 90 DAYS FROM THE OVAL DATE. 00 NOT WRITE IN ANY SHADED AROINDICATE PERMIT TYPE BELOW: _TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR i BILLING INFORMATION: Indicate the responsible party to be billed party designated below is different than the the biking b ignature and date be W. Name � v Mailing Address r- O C- k7 - additional PHS-EHO staff time expended beyond permit payment coverage per tank. If the mit applicant, e.g. property owner, the party must acknowledge this responsibility for AUG 19 1998 SAN PBLIC H�muli iEq+r, NVIRONMENT.AL pEAj.pjD1V,,S,;,;,, v EPA SITEPROJECT CONTACT & TELEPHONE 120 Jl F A FACILITY NAME �.� � a/ - �Q C/ PHONE *,4a/y 1 , C 1 ADDRESS / >�� L I CROSS STREET T OWNER/OPERATOR ktC a,,., -f p a p r. PHON�;g G I '6v Y I 2 -330/ E/-,338 aCONTRACTOR NAME � � �� PHO!4f' _ 6G Up N CONTRACTOR ADDRESS Ptd, o� 3L11j �� b/G7vl8i0 CA LIC A CLASS 4 T/ R INSURE: C,� WORK.COMP.0 C OTHER INFORMATION T PHONE % PH04E 9 1111111311i111i11i1i1111111111 TANK ID 4 TANK SIZE CHEM! L STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED C 39- Z T 39- A 39- N 39- 9- 39- 39- 39- 39- 39 - 39- P P L APPROVED APPROVED WIT CONDITION(S) DISAPPROVED A (SEE TTACN ITH CONDITIONS) N PLAN REVIEWERS NAME DATE /� Y 111111111111111111111111111 1 it II 11 ! 11111 I II11 III!!II hili i 11 1 111111 11111i1111111111111111lI11111 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN IN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE S. OWN OR L SED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMI IS I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNI " CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR W H THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNI " APPLICANT'S SIGNATURE: `� TITLE lAee;1/ DATE 0-," BILLING INFORMATION: Indicate the responsible party to be billed party designated below is different than the the biking b ignature and date be W. Name � v Mailing Address r- O C- k7 - additional PHS-EHO staff time expended beyond permit payment coverage per tank. If the mit applicant, e.g. property owner, the party must acknowledge this responsibility for AUG 19 1998 SAN PBLIC H�muli iEq+r, NVIRONMENT.AL pEAj.pjD1V,,S,;,;,,