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r�=a' `} APPLICATION FOR UNDERGP' 11 TANK RETROFIT, TANK LINING, OR PIPING REr " R PERMIT Ty i THIIP MIT WIRES 90 DAYS FROM THE APPy.4AL DATE. DO NOT WRITE IN ANY SHADED AREAS. .,JDICATE PERMIT TYPE BELOW: V/` TANK REPAIR/RETROFIT TANK LINING `" PIPING REPAIR 31LLING INFORMATION: Indicate the responsible party to be billed for additional PNS-EHD staff time expended beyond permit payment coverage per .:nl:. 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're�'��-'llC.- Mailing Address �.� . l� Q -,c-- 6 Day Phone Num Signature t 9L.. �•--d._ r::v= ._ l Z 003II 7— - �ollke, s",...4 a -d re> zy,-d 6:c��.�-„M,3 �1v , wd - , � c,-rc. r.� d' a�.�rv,r�c� ,�'t' ea'•v'rek �f, hx EPA SITE A' PROJECT CONTACT & TELEPHONE -4fw-�`�: 7 ACILITY NAME t� C PHONE A` C ADDRESS _ L CROSS STREET c 7 OWNE OPERATOR vj�i /—Cr' PHONE #z(jC�" t/y` `✓ \ Y+ ( ' r(I C CONTRACTOR NAMES -�`— PHONE # - 0 N CONTRACTOR ADDRESS CA LIC K / CLASS ' T WORK. COMP.#Rv0j/, R INSURER _ �, , _ A C OTHER INFORMATION - T 0 PHONE # - R Illlllillllllilltlllllll TANK IO # TANK PHONE # TA1JY. S17C CHEMICALS ::iORE_D CURRENTLY/PR[VIOUSLY DATE UST IN`:,T.1LLF:D 39 -mss: - �— T 39- � A 9- N 39- — K 39- 39- 39- 1111 APPROVED L APPROVED WITH CONDITION(S) DISAPPROV`EWONMISE�V�CE� A ,% -(SEE ATTACHMENT WITH CONDITIONS) PES �} 1' — LAN REVIEWERS NAME �111111111lII111111 111 II 111IIl 1 Il III{1111111111 ! 1 111111 lkllll{II 1 1!11!1 Isl 1111 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIOtdS 3F SAN JOAQUIN COUNTY PUBLIC HEALTH S RVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY TII•`.T IN THE PERFORMANCE OF THE WORK FOR WH H THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECC"I'L SUBJECT TO WORKER'S COMPE L S OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE ANCE E--WORK_FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORY,,--,S COMPENSATION LAWS OF CA" TFO APPLICANT'S SIGNATURE: Vii• DATE ^• �'- 31LLING INFORMATION: Indicate the responsible party to be billed for additional PNS-EHD staff time expended beyond permit payment coverage per .:nl:. 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're�'��-'llC.- Mailing Address �.� . l� Q -,c-- 6 Day Phone Num Signature t 9L.. �•--d._ r::v= ._ l Z 003II 7— - �ollke, s",...4 a -d re> zy,-d 6:c��.�-„M,3 �1v , wd - , � c,-rc. r.� d' a�.�rv,r�c� ,�'t' ea'•v'rek �f, hx