Laserfiche WebLink
• tMVIKUnn[eln6 nems n WIVISIUN 0 <br />APPLICAiI0«4 FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: 2, a,, A <br />TANK REPAIR/RETROFIT TANK LINING PIPING REPAIR X t-fAA- !L� <br />BILLING INFORMATIC14: <br />Indicate the responsible party to be billed for additional PHS -END 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 />Mailing Address_ <br />Day Phone Number <br />Signature <br />?3-0038 <br />9 1 0 <br />EPA SITE 0 <br />PROJECT CONTACT L TELEPHONE 0 <br />F <br />FACILITY NAME 7-11 <br />PHONE 1) 3 <br />A <br />C <br />ADDRESS 7-7z,S GGvb BL VO• <br />1 <br />L <br />CROSS STREET <br />I <br />T <br />OWNER/OPERATOR <br />PHONE # <br />C <br />CONTRACTOR NAME r�.,,��NpLo(- itJO� <br />PHONE N Seo „ 9�o y -O/ SO <br />0 <br />N <br />CONTRACTOR ADDRESS IYZo W . kA[TTt41*j,F„/ Uq,,,,Q -.T1r T. <br />CA LIC # <br />CLASS <br />T <br />, -4. 9SSVa• <br />WORK.COMP.N <br />R <br />INSURER <br />A <br />C <br />OTHER INFORMATION <br />T <br />PHONE # <br />0 <br />R <br />PRONE # <br />TANK ID # TANK 512E CHEMICALS STORED CURRENTLY/PREVIOUSLY GATE UST INSTALLED <br />39- + z M 119& 4,104f % ,986 '-0AO0lO <br />T <br />39- u 4— <br />9 Do <br />uw�unOL.4 <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P <br />L <br />���� <br />APPROVED _ APPROVED WITH CONDITION(S) <br />_ DISAPPROVED <br />A <br />(SEE ATTACHMENT WITH CONDITIONS) <br />N <br />PLAN REVIEWERS NAME <br />DATE <br />APPLICANT <br />MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN <br />JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE <br />CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY <br />ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, <br />I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />'_ J <br />TITLE <br />OP004rrT s�`%F•�Alri�'�- DATE 9-8-9J <br />APPLICANT'S <br />SIGNATURE: /' "?/ <br />BILLING INFORMATIC14: <br />Indicate the responsible party to be billed for additional PHS -END 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 />Mailing Address_ <br />Day Phone Number <br />Signature <br />?3-0038 <br />9 1 0 <br />