COMPLIANCE INFO_1986-2003 - Laserfiche WebLink

Home Browse Search

f 0 ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO IN'ANY SHADED AREAS. INDICATE PERM TYPE BELOW: I1lI111llilillllllillllll1I111 TANK IO TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- 3 39- A 39- N 39- K 39- 39- 39 - Illi P L _ APPROVED _ APPROVED WITH CONDITION(S) _ DISAPPROVED A (SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME DATE I11111111111111111lfilll!11111 111111 1 11 111 i 111 1!1 11111 it i Il I 1 111111 111111111111]III111111llIII I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN 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 COMPENSATION 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." � ✓ f v 'i n APPLICANT'S SIGNATURE: TITLE DATE 7 BILLING INFORMATION: Indicate the responsible party to be bitted for additional PHS-EHD 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 billing by signature and date below. Name 7-t 11/01z-1< V Mailing Address 19C- ls"eX ��7ys % �'��c�✓7Day Phone Number (S C Signature EH Z3-0038 1 _TANK REPAIR/RETROFIT _TAMC IIN�NG _ PIPIXG REPAIR EPA SITE 9 PROJECT CONTACT & TELEPHO�JEr �(� �' �� _ �� 7 F FACILITY NAME " —RLI PHONE '# A C ADDRESS CIS 1 I L CROSS STREET I T OWNER/OPERATOR � PHONE # C I CONTRACTOR NAME —/Lri�nt: `� �/`nr�✓ �7/✓G PHONE 9 tf/&-_ .,7i Z v' 0 NCONTRACTOR ADDRESS �� ' [L) �/ .�vl� z3L��-- . CA LIC # CLASS T R I INSURER WORK.COMP.# A C OTHER INFORMATION T 0 PHONE # R PHONE # I1lI111llilillllllillllll1I111 TANK IO TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- 3 39- A 39- N 39- K 39- 39- 39 - Illi P L _ APPROVED _ APPROVED WITH CONDITION(S) _ DISAPPROVED A (SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME DATE I11111111111111111lfilll!11111 111111 1 11 111 i 111 1!1 11111 it i Il I 1 111111 111111111111]III111111llIII I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN 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 COMPENSATION 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." � ✓ f v 'i n APPLICANT'S SIGNATURE: TITLE DATE 7 BILLING INFORMATION: Indicate the responsible party to be bitted for additional PHS-EHD 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 billing by signature and date below. Name 7-t 11/01z-1< V Mailing Address 19C- ls"eX ��7ys % �'��c�✓7Day Phone Number (S C Signature EH Z3-0038 1