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ENVIRONMENTAL HEALTH DIVISION a ^ 'y APPLICATION FOR UNDERGRO 'ANK RETROFIT, OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THEAWRqVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: !r/ K �la� 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. J Name ��-- ,� ddress �(i"► ohcne number `- T — Signature /. 6.. EH 23-0038 / E A SITE # I PROJECT CONTACT &TELEPHONE #� �I� r �, I. i Vii` D _Lb ii = FACILITY NAME C Lx S PHONE # A C ADDRESS 6 G I Y ZO L CROSS STREET i T Y 0 OPERATOR PHONE # O' CONTRACTOR NAME r . ^ /� �/'� y, I PHONE # O N T CONTRACTOR ADDRESS CA LIC # ' CLASS ` I AINSURER /moi I . J1 /� �4J WORK. COMP. # ' 6 6 Z i Ti I'� lA" CCC///��"' / / C OTHER INFORMATION I T 0 PHONE # i i R PHONE # ��I11111111111111111111111111I T K ID # :C SIZE CHEM) CALj STORED CURRENTLY/PREVIOUSLY DAT.: DST INSTP.;..:.ED 39- An T 1 39- A I 39- N I 39- K 39- 1 39- 39- rAPP_CVED ' APP ED WITH CONDITIONS) ,DISAPPROVED A(SEE ATTACHMENT WITH CONDITIONS) c ` N PLAN REVIEWERS NAMEhvZ�DATE 7 ---i�IIIIIIII111111111[11111`11111111111111111111111 If 11111111111 fill if 111111111111111111111111111If11111[11fill II111fill IfIIIIIIIIIf� APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN :OAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TH S PERMIT ISISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORK: ORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT I. -HE PjERFOF�LfANC OF TH ORK FOR "`HIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF APPLICANT'S SIGNATURE: ._. &C 49AMCJZ;/ ATE 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. J Name ��-- ,� ddress �(i"► ohcne number `- T — Signature /. 6.. EH 23-0038 /