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_ <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FRGM THE APPROVAL DATE- DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW-- <br /> TANK REPAIR/RETROFIT __TANK LINING PING REPAIR <br /> EPA SITE T I PROJECT CONTACT & TELEPHONE # <br /> F FACILITY NAME y <br /> A C�(rc� PHONECJ� �JL� 2C.J <br /> C ADDRESS % � � �---/_ 1 <br /> I <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR ) <br /> Y PHONE # <br /> �7 /1 <br /> C CONTRACTOR NAME x G( L�! �' - I /� /) r <br /> 0 PHONE 3 � G% <br /> N <br /> T CONTRACTOR ADDRESS r <br /> _. � _j CLASS <br /> Z <br /> OTHER INFORMATICN <br /> 1 <br /> { PHONE # <br /> 1l11[I1(lltlllll111lliilllIlIl iii PHONE it <br /> TANK ID � TANK SIZE <br /> 39 CHEMICALS STORED CIRRENTLY/PREVICUSLY DATE UST INSTALLED <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> Il11 <br /> APPROVED WITH CCHDITICN(S) DISAPPROVED <br /> PLAN REVTE'dERS NAME (S TACHMEHT WITH CONDITIONS) <br /> tlillllillli111liI1II11tl! 1!1lI1111 lil!l1111iDATE <br /> 111111i11 lilil11i111111ii1iil 11 11IlIIIlilii111l1 III FillIII!!1 11!!1111111 <br /> PPL ICANT MUST PERFORM ALL DORY. IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> AN JCAOUIN CJIJNTY PUBLIC HEALTH SERVICES_ OWNER OR LICENSr: AGENT'S SIGNATURE CERTIFIES THE FOLLOWI.YG: "I CERTIFY THAT IN <br /> HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT c.MPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> JB.:ECT TO WORKER'S COMP"YSATICN LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING_ <br /> I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS LAWS OF CALIFO AISSUED, I SHALL EMPLOY PERSONS SUBJECT TO L7CRKER'S <br /> :.MPENSATIC.v _" <br /> I <br /> 'PLICANT'S SIGNATURE: 7271 ���U/�/'lu-"PA� <br /> NG INFORMATION: <br /> are the responsible party to be billed for additional PNS-cH0 staff time <br /> designated below is different than the permit applicant, expended beyond permit payment coverage per tank_ If the <br /> iEl-ing by signature and date below e-g- property owner, the party must acknowledge this responsibility for <br /> ' 1 <br /> v <br /> 19 Address <br /> Ione x <br /> 'cure ' <br /> 0038 . <br /> :a. - <br />