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MFIRCNMENTAL F-EALTH DIVISION <br />i APPLICATION FOR TMFRGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 9Q DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PrtPmT TYPE BELOW! <br />TANK Rk'MOFIT PIPING REPAIR <br />-c PA SITE 3 <br />PROSECT CONTACT & TELEPAON£ R <br />FAC; LITY...NAME <br />A <br />C ss i i <br />CROSS ST.REE= <br />T I OWNER/OPERATOR <br />j CONTRAC'-0R NAME /. _ e6. - % PHONE a ^� <br />0 <br />N ( CONTRACTOR ADDRESS <br />R � ;NSORER <br />a <br />C OTHER INFORMATION <br />111N111#lilltill111liilltll#1� —� <br />TANK •D d TANK SIZE <br />CA LIC 4 I CL,AS5 <br />WORK. COMP.* <br />PHONE A <br />?HON*_ d <br />CHisMxCALS STORED CU"RRE.YTLY/PREVIOUSLY DAIS' UST TNSTA'_'-ED <br />39- <br />1111t##fllll•Illel"{IIIIII#1ltlltlllllllllilllll <br />lltllllltl I1lI1111lII t�lllll#Ilfl i�llitlll#li lil11i111t1�11-Illiilll�'I�IIj <br />1 APPROVED <br />APPROVED WZIN CONDITION(S1 DISAPPROVED �f f <br />.. <br />W CONnfII0N51 1 1 <br />DAIS' ®�/1 <br />N I 2LAN REV. NFN1E <br />W11 <br />flfll 1111 11111111! I1111111111illltll1111 1111 ttlll lllilt11i11� <br />—II11[IIIlIli111t1111f11I11111 II111111 111 <br />ALL WORK IN ACCORDANCE WITH <br />SAN .:OACUIN COUN:'Y ORDINANCES, STATE LAWS, AND RUL>S AND REGULATIONS CF i <br />APPLICWt' MUST. PERFORM <br />HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIONAT'URE CERTIFIES TWF FOLLOWING: — CSRTT-Y T'iAT IN <br />SAN JOACUIN COUN':Y <r;aL_C <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS ID BECOME <br />THE PERFORMANCE OF Tr(= WORK FOR WHIC;t <br />CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNAT•,TRE CERT;FIrS THE FOLLOWING:( <br />SUBJECT TO WORKER'S CCMPPNSATION LAWS OF CALI=ORNIA•" <br />'CR <br />PERMIT IS ISSUED, 1511At.L EMPLOY PERSONS SLB.TECI TO WORkER'S I <br />CERTIFY ThAT IN THE PERFORMANCE OF 74S W16G <br />WHICH THIS <br />_CMPENSATION TbAws OF call".,RN <br />C <br />-TITLE <br />-_ <br />.aPPL:CANT'S a-wNA'SUR&: �-"�.." "" <br />DATE <br />nILLING INFORMATION! <br />Indicate the responsible party to be billed for additional FHS-EHD staff time expended beyond <br />permit payment coverage per tank. if the party designated below is different than the permit <br />applicant, e.g. property owner, the party must acknowledge this responsibility for the billing <br />by signature and elate below. ��'j$ j4,G <br />Name ace ess 5-'/J`"' "��'�`hone number, ( <br />�.� - <br />Signature <br />EH 22-0038 i) au muof <br />VS ViiPI) 1441 Cqu)-pMp,� wwh�� mt4�+ �e <br />TO 39dd f JNIA Id 6VZP66960Z 9b:60 0002/0T/TT <br />