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POA ERQAOUND ENVIRONMEYTAL HEALTH DIVISION <br />a APPLICATION TANK RIiROFIT, OR PIPI}60 REPAIR P <br />THIS PERMIT EXPIRES 90 DAYS MOM THE APPROVAL'DATE, 00 Wr WRITE IN ANY SHADED AREAS INDICATE PERMIT TYPE BZLOW <br />TANK ID ! TANK SIZE CHEMICALS STORED CVRAZMY/PRZVIOUSLY DATE UST INSTALLED <br />)9• I <br />T )9- <br />A )9- <br />N 79- <br />R )9- <br />79• ' <br />P <br />L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITIONS) I <br />v PLAN RIVIIWERS NAME DATE <br />11111111111111111111 11111 t <br />PLICANT MOST PIRPORM ALL WORE IN ACCORDANCE WITH SAN JOAQVIN COUNTY ORDINAWCIS, STATE LAWS, AND RVLE3 AND REGULATIONS OF <br />SAN JOAQUIN COUNTY P(IBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE C$RTIPIES THE FOLLOWINCt •I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH IS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME i <br />SUBJECT TO WORKER'S COHPENSATION LAM 0 CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES rIx FOLLOWING:I <br />•I TEKTITE THAT IN THY FOROKZ� WHICH THIS PERMIT IS ISSUED, E SHALL IMPEDE PERSONS SUBJECT TO YORKER'S <br />C.MPENSATION WWS OF <br />APPLICANT'S SICNATVRI: TITLE <br />BILLING INFORMATION: <br />Indicate the responsible party- to, bq billed for additional PHS-EHD staff time expended beyc <br />permit payment comerage per tank. If the party designated below is different than the pern <br />applicant, e.g. property owner, the party must.acknowledge this responsibility for the bi11i <br />by signature and date�­below. <br />Name I d esafZ�5, A? 4hone number <br />Signatu a <br />EH 23-0038 <br />1 <br />-Ik <br />RETROFIT MING <br />__TANK REPAIR' <br />6PJ1 SITE !PROJECT <br />CONTACT i TELEPHONE I <br />y <br />FACILITY <br />crus <br />A I NAMEC� a s <br />PHONE 1 V <br />$� <br />C I ADDRESS /'Z % <br />S <br />��jID V r� <br />Z <br />L CROSS STREET <br />� <br />I <br />� <br />T I OWNER/OPERATOR <br />.�PHONE �1 <br />I <br />C COKTTtJ1CTORNAND' i <br />0 <br />` e <br />PHONE ! T �' <br />N ( CONTRACTOR ADDRZSo <br />( 1 <br />�--C < <br />CA LIC ! <br />CLASS <br />T <br />. <br />1' <br />R INSURER <br />WORKCOMP.1 <br />A <br />C <br />OTHER INFORMATION <br />T <br />j <br />0 <br />R <br />PHONE 1 <br />I <br />� 11111111111111111111111111111! <br />PHONE 1 <br />I <br />TANK ID ! TANK SIZE CHEMICALS STORED CVRAZMY/PRZVIOUSLY DATE UST INSTALLED <br />)9• I <br />T )9- <br />A )9- <br />N 79- <br />R )9- <br />79• ' <br />P <br />L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITIONS) I <br />v PLAN RIVIIWERS NAME DATE <br />11111111111111111111 11111 t <br />PLICANT MOST PIRPORM ALL WORE IN ACCORDANCE WITH SAN JOAQVIN COUNTY ORDINAWCIS, STATE LAWS, AND RVLE3 AND REGULATIONS OF <br />SAN JOAQUIN COUNTY P(IBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE C$RTIPIES THE FOLLOWINCt •I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH IS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME i <br />SUBJECT TO WORKER'S COHPENSATION LAM 0 CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES rIx FOLLOWING:I <br />•I TEKTITE THAT IN THY FOROKZ� WHICH THIS PERMIT IS ISSUED, E SHALL IMPEDE PERSONS SUBJECT TO YORKER'S <br />C.MPENSATION WWS OF <br />APPLICANT'S SICNATVRI: TITLE <br />BILLING INFORMATION: <br />Indicate the responsible party- to, bq billed for additional PHS-EHD staff time expended beyc <br />permit payment comerage per tank. If the party designated below is different than the pern <br />applicant, e.g. property owner, the party must.acknowledge this responsibility for the bi11i <br />by signature and date�­below. <br />Name I d esafZ�5, A? 4hone number <br />Signatu a <br />EH 23-0038 <br />1 <br />-Ik <br />