COMPLIANCE INFO_1994-2001 - Laserfiche WebLink

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11cHL111 UIVISION y *� ICATION FOR U GROUND TANK RETROFIT, TANK LINING, OR PIPIN EPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE .APPROVAL DATE. DO NOT WRITE IN ANY SHADED A , S. INDICATE PERMIT TYPE BELOW: _TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR PHONE Of lllltllllllllll litllllllllltll 39 - TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED T 39- A 39- N 39- K 39- 39- 39- P 1111ffTffflTrrrim L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED A ISEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME DATE Cj IlIllllil111111111111 111 11 II IIII 11111 illlll Illlllill 111 111 I I I Ili 111111 III IIIII H -If fill i 11 IIIIIIi APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 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 COMPENSATION LAWS OF CALIFORNIA " � APPLICANT'S SIGMA RE: 7 TITLEC :.a: ( DATE C 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 b' 1 by signature and a elow. Name ^�-��Ph /� �A Mailing Address IJ� 1 •,.� AC� T(1%j , 0/ )1/1 ( I. Vim- ( .1�� / _f__ EPA SITE # PROJECT CONTACT & TELEPHONE # f y I ��^% F A FACILITY NAME I j� - PHONE # �C�7 �!/ I ADDRESS ' ` C yN�-— - Q ) /V L I CROSS STREET �[ T OWNER/OPERATOR PHONE # Y V%�_ C CONTRACTOR NAME ) PHONE # 0 T CONTRACTOR ADDRESS .� X. /� - CA LIC # ` CLASS 7� R INSURER ,A ^� 'e—N ��, WORK.COMP.# ��`jV C OTHER INFORMATION T 1 0 R PHONE # PHONE Of lllltllllllllll litllllllllltll 39 - TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED T 39- A 39- N 39- K 39- 39- 39- P 1111ffTffflTrrrim L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED A ISEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME DATE Cj IlIllllil111111111111 111 11 II IIII 11111 illlll Illlllill 111 111 I I I Ili 111111 III IIIII H -If fill i 11 IIIIIIi APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 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 COMPENSATION LAWS OF CALIFORNIA " � APPLICANT'S SIGMA RE: 7 TITLEC :.a: ( DATE C 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 b' 1 by signature and a elow. Name ^�-��Ph /� �A Mailing Address IJ� 1 •,.� AC� T(1%j , 0/ )1/1 ( I. Vim- ( .1�� / _f__