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APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br />PWS, PERMIT EXPIRES 90 DAYS FROM THI NOVAL DATE. DO NOT WRITE IN ANY SHADED A INDICATE PERMIT TYPE BELOW: <br /> TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br /> EPA SITE I PROJECT CONTACT & TELEPHONE I <br /> AFACILITY NAME _ M (7C ✓_ t PHONE 9 <br /> I ADDRESS -7 4,1 .7C 1 <br /> L CROSS STREET <br /> I GC 13 <br /> `L le.1—• <br /> T OWNER/OPERATOR PHONE # <br /> Y <br /> C CONTRACTOR NAMEPHONE 0 <br /> 0 ' Cc z✓5 17 Cc-,n--ell 4-i/ <br /> N CONTRACTOR ADDRESSf t� CA LIC 0 CLASS <br /> R INSURER WORK.COMP.# <br /> A <br /> C OTHER INFORMATION <br /> F9- <br /> PHONE # <br /> PHONE <br /> TANK ID # TANK SIZE CHEMICALS ST99RED CURRENTLYIPREVIOUSLY DATE UST INSTALLED <br /> ars / rlel m;eic -r,de CykSo (, � �� <br /> T 39 <br /> A 39- <br /> N 39- <br /> 4 39- <br /> 39- <br /> 39- <br /> P 111111 1111 <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> Il11111111111111111111111111111111illlll111111! IIII I 11 III 11 111 !1! 1 I I it 111111 Iiillii1111111111111111111lII <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: ^ � / TITLE 1-e 41c,.'C149" 'T DATE 2 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the <br /> party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br /> the bitting by signature and date below. <br /> Name <br /> Mailing Address <br />