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ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REP PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FRCM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br />31LLING INFORMATION:. <br />Indicate the responsible party to be billed for additional PHS•EHO staff time expended beyond permit payment coverage per tank. If the <br />oarty designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br />the biking by signature and date below. <br />Name <br />Mailing Address <br />Day Phone N <br />Signature_ 7 <br />EPA SITE 0 <br />PROJECT CONTACT & TELEPHONE 0 g e <br />F <br />FACILITY NAME <br />✓P <br />PHONE A- <br />A <br />C <br />I <br />ADDRESS <br />L <br />CROSS STREET <br />I <br />T <br />CWNER/OPERATOR <br />PHONE 9 <br />Y <br />C <br />CONTRACTOR NAME_ <br />PHONE r. r` <br />® 1 , <br />0 <br />N <br />T <br />CONTRACTOR ADDRESS P-6- <br />S.a <br />CA LIC 9 CLASS i <br />> <br />R <br />INSURER1 <br />WORK.COMP.: <br />A <br />C <br />OTHER INFORMATION <br />T <br />0 <br />PHONE I <br />R <br />1111i1fIllilfl1I1111I1IIllI111 <br />TANK IO T <br />PHONE <br />TANK SIZE CHEMICALS STORED CURRENTLY/PREVICUSLY DATE UST INSTALLED <br />39- <br />19: <br />_.. <br />3 <br />K <br />39- <br />39- <br />P <br />lfll <br />L <br />ell APP <br />ED APPROVED WITH CCHDITION(S) DISAPPROVED <br />A <br />_ <br />S ATTAC NI WITH CONDITIONS) <br />M <br />PLAN REVIEWERS NAME <br />(1lifflllllllifll1111 11111 <br />DATE <br />111!11 fill if Ill II II I III !I Ifllillllilftlf Illi! ]!!!!litllilllllf t <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCZ OF THE WORK FOR WHICH <br />THIS PERMIT IS ISSUED, I SHALL MOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S CCMP£NSATICH LAWS OF CALIFORNIA." CONTRACTCR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"t <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALI IA.'- <br />(; <br />APPLICANT'S SIGNATURE: <br />t <br />TITL VIM/ <br />31LLING INFORMATION:. <br />Indicate the responsible party to be billed for additional PHS•EHO staff time expended beyond permit payment coverage per tank. If the <br />oarty designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br />the biking by signature and date below. <br />Name <br />Mailing Address <br />Day Phone N <br />Signature_ 7 <br />