COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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ENVIRONMENIAL HEALTH DIVISION APPLICATION FOR UNDERD TANK RETROFIT, TANK LINING, OR PIPING R# PERMIT Yi r c'.HIS PERMIT EXPIRES 90 DAYS FROM THE APP OVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: • TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR BILLING INFORMATION: S 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 billing by signature and date below. \ Name Mailing Address �►..v�� n r��Z , &I T — kVV 01e.s ACflcii V2;®cz 4-0 A;�1;�-w�c,�,� ��? 1° EPA SITE # PROJECT CONTACT & TELEPHONE it F A FACILITY NAME � L� � � PHONE # � cc` Z� C 1 ADDRESS ' L CROSS STREET I T OWNER/OPERATOR PHONE # \ a_ -1 C 0 CONTRACTOR NAME^ PHONE # N CONTRACTOR ADDRESS CA L # _ CLASS. T ` R INSURER �� WORK.COMP. A C OTHER INFORMATION T 0 R PHONE # III 111 I 11111111111 I 11111111111 TANK 1D # TANK SIZE PHONE # �_ CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED T 39- A 39-_�� N 39- cct`.,c_ �;� L♦ K 39- 39- 39- P 11111111111111 1111111111111 1111111111111111111111111111 MUM L APPROVED _ APPROVED WITH CONDITIONS) DISAPPROVED A fkTTACHMENT _ WITH CONDITIONS) , N PLAN REVIEWERS NAME II111111111111111111 11 DATE I I 11 I !1(111 111111 11111(1 1 III III APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "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." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFOR E OF THE WORK F R WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFOR [A.' APPLICANT'S SIGNATURE: 2 TITLEDATE �" �l►2tri �1,� > 6 �i BILLING INFORMATION: S 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 billing by signature and date below. \ Name Mailing Address �►..v�� n r��Z , &I T — kVV 01e.s ACflcii V2;®cz 4-0 A;�1;�-w�c,�,� ��? 1°