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ENVIRONMzYCAL HEALTH DIVISION <br />APPLICATION FOR vkmtom TANK. RETROFIT, OR PIPING REPAIR PSAW <br />THI3 PERMIT EAPIRSS 90 DAYS FROM THE APPROVAL' DATE, DO NOT jutm IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />__TANX RETROFIT k - PYP REPAIR' <br />SPA SITE I PROJECT CONTACT i TELEPHONE I IAJI�- ✓ D -p F, ^P. i <br />r' I FACILITY NAMY<:Z' <br />A PxoNE / g 6 <br />cI ADDRESS /2/`T c0 <br />I <br />L I CROSS MZZT <br />I <br />T I OWNER/OPERATOR PHONE I <br />OC MNTRACTOR NAHi , PHONE 1 Y 8` <br />TCONTRACTOR ADDRES�<) a ( t ,r� CA LIC 1 CLASS, 6 ` l <br />R INSURER (• �� (V WORX.COMP.I 6Z� <br />A `. r_ <br />C OTHER INFORMATION i <br />T <br />0 PHONE I j <br />R <br />PHONY 1 I <br />Illllilllllllllllllllllllltlll <br />TANK ID I TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />)9- <br />T )I- <br />A <br />9-A )9- <br />I <br />N 79• <br />i <br />R )9• <br />)9- <br />II11 !) <br />P <br />L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITIONS) <br />:! <br />PLAN REVIEWERS NAME DATE <br />1!111011111111111111 11!11 <br />PLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQVIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGVLATIONS OF <br />SAN JOAQUIN COUN'T'Y PUBLIC WEALTH SERVICE$. OWNER OR LICENSED AOEMT'S SIGNATURE CERTIFIES THE FOLLOWING: °I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICR IS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS To BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWJ Ot CALIFORNIA.* CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:] <br />'I CYRTIFT THAT IN CRY FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S i <br />Ca04PENSATIOH LAWS OF • <br />• �i �C I <br />APPLICANT'S SIGHATVRS: TITLE <br />BILLING INFORMATION: <br />Indicate the responsible party,-to..bq billed for additional PHS-EHD staff time expended beyc <br />permit payment cwverage per tank. If the party designated below is different <br />•.than the perp <br />applicant, e.5. prope.rty owner, the party must.aeknowledge this responsibility for the billi <br />by signature and date ­below. <br />S ignatufA\. <br />EH 23-0038 <br />..�� c .� i a <br />1 <br />J, <br />