COMPLIANCE INFO_1988-2007 - Laserfiche WebLink

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APPLICATION FSA UND -011,:ANK RETROFIT, OR PIPING REPAIR PERMIT 'r -HIS PERMIT EXPIRES 90 DAYS FRCM THE APPROV;,=. DATE. DO :TOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOWi 1 PHONE # I --1ftftlttttltllil(ttltl a Ittllt![ = TANK ZD # TA-'` SIZE CHEMICALS STORED CURRENTLY/ PREVIOUSLY DAT£ UST INSTALLED 1 39- T 9 T ! 39- t II I A t 39- I I I N ! 39- 1 K t 39- 39- 39- APPROVED 9-39-APPROVED APPROVED WITH CONDI--ON(S) DISAPPROVED ! (SEE ATTAC''1tE4T WITH CONDITIONS) t N 1 PLAN REVIEWERS NAME - DATE —Illltltllllllll1111(llilltll!ltlllt[It111111111ttlillltllllitllflltltllltt111lltlllilllifl11tt1t111tHtlfltlltllllllIltl!ltlllt s APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE ::ITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND .REGULATIONS OF j SAN JOAQUIN COUNTY ?UBLIC HEAL_3 SERVICES. C---N-ER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN j T— PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A .BANNER AS TO 3ECOME. SUBJECT TO WORKER'S COMPENS Ov LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:i I CERTIFY THAT IRT THE PERF -JCE OF THE WGRS FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S I COMPENSATION :.AWS OF CALIF RN A.' APPLICANT'S SIGNATURE: TITLE QU ® ® CJ I B ILLING INFORMATION: Indicate the responsible party to be billed 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 si ture and date bel 74 Name d ess hone number (�" Signature EH 23-0038 1 _TANK R_cT=OFIT PIPING REPAIR I EPA SITE # PROJECT CONTACT TELEPSCNE # -.. FACILI:'Y NAME ONE # C I ADDRESS I Z L I CROSS STREET Z � T I OWNER/OPERA R I PHONE - -I At I , C j CONTRACTOR N E A0 )LillPHONE - ® # ,. I rl N I CONTRACTOR ADDRESS f p I CA LIC X/ In I CLASS �f I� I T !J ® T R I INSURER I WORK. COMP _3 C I OTHER INFOR,'ATION I I T O I I PHONE # I R 1 PHONE # I --1ftftlttttltllil(ttltl a Ittllt![ = TANK ZD # TA-'` SIZE CHEMICALS STORED CURRENTLY/ PREVIOUSLY DAT£ UST INSTALLED 1 39- T 9 T ! 39- t II I A t 39- I I I N ! 39- 1 K t 39- 39- 39- APPROVED 9-39-APPROVED APPROVED WITH CONDI--ON(S) DISAPPROVED ! (SEE ATTAC''1tE4T WITH CONDITIONS) t N 1 PLAN REVIEWERS NAME - DATE —Illltltllllllll1111(llilltll!ltlllt[It111111111ttlillltllllitllflltltllltt111lltlllilllifl11tt1t111tHtlfltlltllllllIltl!ltlllt s APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE ::ITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND .REGULATIONS OF j SAN JOAQUIN COUNTY ?UBLIC HEAL_3 SERVICES. C---N-ER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN j T— PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A .BANNER AS TO 3ECOME. SUBJECT TO WORKER'S COMPENS Ov LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:i I CERTIFY THAT IRT THE PERF -JCE OF THE WGRS FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S I COMPENSATION :.AWS OF CALIF RN A.' APPLICANT'S SIGNATURE: TITLE QU ® ® CJ I B ILLING INFORMATION: Indicate the responsible party to be billed 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 si ture and date bel 74 Name d ess hone number (�" Signature EH 23-0038 1