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E ' ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT C, THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOP WRVE IN'A9Y SHADED AREAS. INDICATE PERM TYPE/ BELOW: _TANK REPAIR/RETROFIT _TANS IN,�NG _ -prkNG REPAIR e _ 4 A rL11,�w7L BILLING INFORMATION: Indicate the responsible party to be bitted for additional AHS-EHO 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 biLting by signature and date below. ,/J 4 Mailing address �� eex CIA 7ys�-77 Day Phone Number (S% 0) G S 7 �';� �� 0 Signature EH 23-0038 1 2,;Vc EPA SITE # PROJECT CONTACT & TELEPHOFlE 0Q, �R/" V 4=z d �, G _ Cr 7 _ e - y& (! FFACILITY NAME /� S �J/J. # ,/ L // PHONE # G' C! �G �7 — / l Z A C ! ADDRESS / w Com. L CROSS STREET I K 7� T Y OWNER/OPERATOR �,� S �'I � � �—KJ PHONE # -7 , -,FJa C CONTRACTOR NAMEPHONE # �/ _ . „� 6 70 2-0 N r CONTRACTORADDRESS �S+ZS- GV)'J� 13L v CA LIC # CLASS R I INSURER WORK.CCMP.# a C OTHER INFORMATION T 0 PHONE R PHONE 1l11111111111111111I111111I1t1 TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- 3 39- A 39- N 39- K 39- 39- 39- P III L APPROVED_ APPROVED WITH DITIONCS) ® DISAPPROVED A (SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME DATE 11I11!l1111111111t11!lttl t!!1!1 ! I 1 U! Itlll I 1 1 1 tlltit tUlllll11111 1 fll flltlli APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOACUIN 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 CCMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." jI APPLICANT'S SIGNATURE: TITLE % r✓✓ -�13C,r0ATE 7 17 97 BILLING INFORMATION: Indicate the responsible party to be bitted for additional AHS-EHO 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 biLting by signature and date below. ,/J 4 Mailing address �� eex CIA 7ys�-77 Day Phone Number (S% 0) G S 7 �';� �� 0 Signature EH 23-0038 1 2,;Vc