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+ A ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERAW TANK RETROFIT, OR PIPING REPAIR PERMIT L THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: TANK RETROFIT PIPING REPAIR BILLING 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 signature and date below. Name address phone number Signature EH 23-0038 1 EPA SITE # PROJECT CONTACT & TELEPHONE # F FACILITY NAME PHONE # A C I ADDRESS L I CROSS STREET I T I OWNER/OPERATOR i PHONE # YI C CONTRACTOR NAME PHONE # 0 N I CONTRACTOR ADDRESS ( CA LIC # I CLASS I WORK.COMP.# I R INSURER L A C I OTHER INFORMATION I 0 I I PHONE # I R PHONE # ---II111111111 11111111111111' TANK ZD # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED TANK 1 39- T 1 39- 1 39- 1 I I I A N I 39- 1 K I 39- --111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111' L I APPROVED APPROVED WITH CONDITIONS) DISAPPROVED A 1 (SEE ATTACHMENT WITH CONDITIONS) N I PLAN REVIEWERS NAME DATE -1111111111111111111111111111111111111111111111111111111111111111111i1111111111111111111111111111111111111111111111111111111111� APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AUND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT iN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S CCMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: TITLE DATE BILLING 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 signature and date below. Name address phone number Signature EH 23-0038 1