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�- L---- _ ENVIRONMENTAL HEALTH DIVISION , APPLICATION FOR�RGROUND TANK RETROFIT, OR PIPING REPAIR P TRIS PERMIT I{J(PIRES 90 DAYS FROM THE APPROVAL- VATS. DO NOT WRITS IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: ®eTANK RETROFIT PIPING REPAIR' LPA SITE I PROJECT CONTACT i TELEPHONE N r� FACILITY NAME A ®, PHONE C ADDRESS �' b l - I a L CROSS STREET 1 ? OWNER/OPERATOR PHONE f Y C CONTRACTOR HAMIC3PHONE I 0.®Cz/' �- N CONTRACTOR ADDRLS ` CA LIC I CLASS 1 T R INSURER WORK.COMP.M A C OTHER INFORMATION T ° PHONE / R � I I I I I I I I I I I I I I I l l I I I I I 11111111 PHONE r TANK ID I TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED )9• T 39- A 9•N 39- N )9• K )9• )9- )9 P 1111 1 L APPROVED _ APPROVED WITH CONDITIONS) DISAPPROVED A (SEI ATTACHMENT WITH CONDITIONS) e N PLAN REVIEWERS NAME iiiiiiiiiiiiiiiiiiiiiillillilifilillilI DATE I I I I I t PLICANT MUST PERFORM AEI: WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICZN$ED AGENT'$ SIGNATURE CERTIFIES THE FOLLOWING: °I CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICR IS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A KANNER AS To BECOME SUBJECT TO WORKER'S COMPENSATION WW 0 CALIFORNIA.' CONTRACTOR'S NIRIHG OR SVECONTRACYING SIGNATURE CERTIFIES THE FOLLOWING: •I CIRTITY THAT YN TRI FOR WHICH THIS PERMIT IS ISSUED, I SRALL EMPLOY PERSONS SUBJECT i0 WORKER'S COMPENSATION WW$ OP APPLICANT'S SIGNATURE: C TITLE ATE m �� BILLING INFORMATION: Indicate the responsible pais=tyto,hp billed for additional PHS-EHD staff time expended beyo permit payment coverage per tank. If the party designated below is different than the perm applicant, e.g, property owner, the party must.acknowledge this responsibility for the bil?ii by signature and date below. Name t�.iP dd esat . 5 hone number ° Signatuast EH 23-0038 1 Jh