Laserfiche WebLink
1�/20/2b00 11:35 209468 FIFTH FLOOR PAGE 02 <br />• ENVZR0NM1RJ AL HEALTH DIVISION <br />AF:LICATION FOR MERGROiMD TAPIR RETROFIT, OR FXPr`_Tu' TLSAIR PERMIT <br />TVZS PERMIT EXPIRES 90 DAYS 8R09I TEE A2PROVAL DATE. 00 NOT KRZTZ IN ANY S-BADED AREAS, Z'MZCATE PERMYT TYPE =,OW: <br />®-.TANK RETROFIT - PI?INC REPAIR <br />EPA SATE A PROJECT CONTACT Z. T£L:,PHONc^ 4 <br />F I FACILITY NAME Q u lK-"%riP f�/-3,(- <br />A <br />f PEONT <br />A Aa2�C �3 f3� C2 eq) g 35- "Zsv <br />C ADDRESS / 163 L /,-J Cv(. N ' a- IJD <br />L <br />i CROSS STREET <br />TER <br />I OWNER/OPATOR i PHONE <br />Y &(AtKSTVP iL11�V-V-TS,IAlc . i C51v� '453-.8*7-.- <br />G ( CONTRACTOR NAMEn21/37�[fyLE c%�Y ✓/2C>A//�(G V //'i�C PxOhc / �/�)�fC-7DZ(� <br />N 1 CON"CRACTOR ADDRESSLIC' t C ASS <br />T ZsZS N✓• BLIiL�,IrC. $LI%15• I <br />: <br />a I INSURER I WORx. cati� _ <br />A � ' <br />C i OTHER INFORMATION <br />0 I PEON. # <br />BILLING INFORMATION: <br />7ndi,eate the responsible party to be billed for additional PHS-EED staff time expended beyond <br />permit payment coverage per tank. If the party designated below is different than the pex'r.:it <br />applicant, e.g. property owner, the party must acknowledge this responsibility for the bil-:ng <br />by signature and date below. w <br />TRIP! -CC CWVtde0„1orCWr4t., Ne. 2S2 -S- 84k6ilUe- B�Jb- <br />Name address bt1,eA4;4, eV , phone number (9/&-) S'/0 7y ZO <br />9�sb5- <br />Signature <br />EH 23-0038 <br />04 <br />I <br />I PscNE m <br />—Illtlitutlifillllllllninnl� <br />TANK ID 0 <br />TAMC SIZE CMMXCALS STORED CURRe'YPLY/PREVIOt;SLY CAT_ VST XNSTALLED I <br />j <br />39- 1 <br />I <br />T 1 <br />39- 1 <br />39- <br />A l <br />39- <br />N l <br />1 <br />35- <br />9-39-?llllilllllillllil1111! <br />39- <br />? 'Illllllilll <br />1.9 VE <br />XAPPROVEO <br />WITH CONDITIONS) DISAPPROV3DA <br />i <br />ACKMEN WITH CONDITIONS) <br />N 1 PLAN RZVIEWERS NAME <br />DATE /S <br />----1[I11t11lIlilllltl111111,41 <br />! ltlfllltlll t 11[itIt1111111111tI1111111tlltlllllltt11111 It W11111 11111111 FIT,tq <br />APPLICANT MUST PeRfOR." ALG WORK IN ACCOROAN(M WITH SAN JOAQUIN COUNTY ORDINAMIC=$, STATr. w1W5, AMID 1"--S AVV REGOLITIOOTS CF <br />SAN JOA=N COUNTY PUBLIC FZALTH SERVICES_ <br />OWNER OR LICSNSeU AGENT'S SIGNATURE CERTIFIES TLiz FOLLOWING: 'L CERTIFY IN <br />THE ?ERFORMANCE OF THE WORK FOR WRICA THIS <br />PERMIT IS LSS'JS'D, X SHALL VCT EM?LOY ANY PERSON IN SUCH A YL4NNER AS TO BECOME j <br />SUBJECT TO WOR= -R'S CCMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S WIRINC OR SUBCONTRACTING SIWATURZ CERTIFIES Ti-- FOLLOWINC:I <br />"I CERTIFY THAT IN THE 2R.2FORMA= 0- THE WORK FOR WTiXCS THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />A22LZCAVI"S SZ09ATVR6: / �-Lz <br />TITL2 GC ILL vc �L� VAT= <br />BILLING INFORMATION: <br />7ndi,eate the responsible party to be billed for additional PHS-EED staff time expended beyond <br />permit payment coverage per tank. If the party designated below is different than the pex'r.:it <br />applicant, e.g. property owner, the party must acknowledge this responsibility for the bil-:ng <br />by signature and date below. w <br />TRIP! -CC CWVtde0„1orCWr4t., Ne. 2S2 -S- 84k6ilUe- B�Jb- <br />Name address bt1,eA4;4, eV , phone number (9/&-) S'/0 7y ZO <br />9�sb5- <br />Signature <br />EH 23-0038 <br />04 <br />