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=•< t APPLICATION FOR UNDERGRCU" TAMC RETROFIT, TANK LINING, OR PIPING REPA ,, PERMIT THiS PERMIT EXPIRES 90 DAYS FROM ZTANK L. _- DATE. 00 NOT WRITE IN ANY SIIADCD AREAS. . ,CUTE PERMIT TYPE BELOW: REPAIR/RETROFIT TANK LINING - PIPING REPAIR APPLICANT MUST PERFORM ALL WORK. IN ACCORDANCE WITH SAN AOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIO;i� ':F SAN JOAQUIN COUNTY PUBLIC HEALTH S RVICES. OWNER OR ENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY T.1i',T IN THE PERFORMANCE OF THE WORK FOR WH H THIS PERMIT IS I SUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECC:'!E SUBJECT TO WORKER'S COMPE L 1JS OF CALIFOR " CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FCL'-CWING: "1 CERTIFY THAT IN THE P FO ANCE C� E-WORKICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT 70 WCR'l.="'S COMPENSATION LAWS OF CA " v APPLICANT'S SIGNATURE: TITLE;: ' r�f i �- DATE TILLING INFORMATION: indicate the responsible party to be billed fo additional PHS-EHD staff time expended beyond permit payment coverage per r.k. If the party designated below is different than the rmit applicant, e.g. property owner, the party must acknowledge this respc:.sibility for :ne biking by signature and date below. lame t' )� i £%C. t�o 0 <� f : aiing address . r• { ��y -- Cay Phone NLAnk ( ) d - j f 1 p p .:I 7-3-0033 � _ �o�/ (il, �� C:UvwATOI -f' r f 1S� � �� �t 0lCO je..s EPA SITE PROJECT CONTACT E TELEPHONE #�� ,, %- , �,� lor Q> NAME PHONE # L.-ACILITY "• A•-• ` C ADDRESS L CROSS STREET - T OHNE OPERATOR riGff.i /-C,' ' PHONE #170-q— �- C CONTRACTOR NAMES r PMONE -� �� N CONTRACTOR ADDRESS O CA LIC h;: d CLASSCW ri ' R INSURER G. ' /�Y'If�.. WORK.COMP.3!?0 j4 j - 42, _. A C OTHER INFORMATION - T 0 PHONE # R II111l1111111111111111illlllll TANK IO # TANK SIZC PHONE # CilCMI ALS SPORED CURRENTLY/PREVIOUSLY DATE UST-INS7ALLED 39- - - , T 39- „ A 9- N 39- ` K 39- 39- 39- 1111 'tl JA APP VED APPR9VE TH CONDITION(S) DISAPPROVE Nv"`� - /,j SEE ATTR H I WITH CONDITIONS) DATE _• LAN REVIEWERS NAME 41nii�ri�tiittu� t ��^titt ^-� �J� It III tit II tllitll1111t11l1 I t Illili It.11llill 1 1!1111 ,`:?! !111 APPLICANT MUST PERFORM ALL WORK. IN ACCORDANCE WITH SAN AOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIO;i� ':F SAN JOAQUIN COUNTY PUBLIC HEALTH S RVICES. OWNER OR ENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY T.1i',T IN THE PERFORMANCE OF THE WORK FOR WH H THIS PERMIT IS I SUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECC:'!E SUBJECT TO WORKER'S COMPE L 1JS OF CALIFOR " CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FCL'-CWING: "1 CERTIFY THAT IN THE P FO ANCE C� E-WORKICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT 70 WCR'l.="'S COMPENSATION LAWS OF CA " v APPLICANT'S SIGNATURE: TITLE;: ' r�f i �- DATE TILLING INFORMATION: indicate the responsible party to be billed fo additional PHS-EHD staff time expended beyond permit payment coverage per r.k. If the party designated below is different than the rmit applicant, e.g. property owner, the party must acknowledge this respc:.sibility for :ne biking by signature and date below. lame t' )� i £%C. t�o 0 <� f : aiing address . r• { ��y -- Cay Phone NLAnk ( ) d - j f 1 p p .:I 7-3-0033 � _ �o�/ (il, �� C:UvwATOI -f' r f 1S� � �� �t 0lCO je..s