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ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br />P R EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br />_TILLING INFORMATION: <br />ndicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the <br />Tarty designated below is different than the rmit applicant, e.g. property owner, the party must acknowledge this responsibility for <br />the bitting by signature and date below. <br />ailing Address //C���' �)C C:- J�IG�� G�r� cG(�/�%. �JC� 2, <br />ay Phone Number (IM5 ) 42 <br />'ignaCure <br />If <br />8 23-0038 <br />EPA SITE # <br />PROJECT CONTACT &TELEPHONE # <br />AFACILITY <br />NAME r'C Q /- 5450 <br />PHONE <br />I <br />ADDRESS /� y V + Fr rim 1�! `OCA � o t,,-� � . �' � D 3 <br />L <br />I <br />CROSS STREET _' — ' ' <br />T <br />OWNER/OPERATOR) ,/ <br />PHONE # <br />OCONTRACTOR <br />NAME TIr,'ah I�C� v c o <br />PHONE # <br />N <br />CONTRACTOR ADDRESS 0, <br />CA LIC # /V 3 5 y o <br />CLASS 1-7—.5 <br />T <br />R <br />INSURER %� Cn'I/�, �'iQ /Ct ll C �� <br />WCIRK.COMP.SI PWC 2o7373 -o <br />A <br />v ti <br />C <br />OTHER INFORMATION <br />T <br />0 <br />R <br />PHONE # <br />PHONE # <br />1111111111111111 ! 11111!!! I l l l l <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />T <br />A <br />i <br />39- <br />39- <br />N <br />39 .r- r'—o�: p <br />Ce - <br />K <br />39-- <br />39- <br />39- <br />Il11ItTTT1T11TITTI11T111f1TITT 1111TH -1H fI11Tf1T ITfiTH 1TfITTTITTTfT111-11ITTiffi]Tf TMffTTMTT f11TTfT IM11TT111TT <br />P <br />L APPROVED ': APPROVED WITH CONOITION(S) DISAPPROVED <br />A <br />tSEEA�AC,HIIENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME / `N� ` DATE <br />- 1!1111111111!III11111111T11I1�TifTI1IIiIIIIIIIIiTiTl111iT1T11T1liT1 I�IIfTI1IT11TTiT11TTiiTIIIIfI If 111111 111II111II 11 II 111 <br />APPLICANT MUST PERFORM ALL 'WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. (7.74ER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 1S ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFCRNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I 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 CALIFORNIA." <br />� r � <br />APPLICANT'S SIGNATURE_ , `! / ���t��i.t\ TITLE �C��S /tl�l•/ / DATE <br />_TILLING INFORMATION: <br />ndicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the <br />Tarty designated below is different than the rmit applicant, e.g. property owner, the party must acknowledge this responsibility for <br />the bitting by signature and date below. <br />ailing Address //C���' �)C C:- J�IG�� G�r� cG(�/�%. �JC� 2, <br />ay Phone Number (IM5 ) 42 <br />'ignaCure <br />If <br />8 23-0038 <br />