Laserfiche WebLink
ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR LW`DERGRb%W0 TANK RETROFIT, OR PI?ING RE FAIR. PERMIT ,"Ww <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT 'WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE 3ELON: <br /> _TANK RETROFIT PIPING REPAIR <br /> EFA SITE X 13PROJECT CONTACT E. TELEPHONE <br /> '� •a•',g � t.� <br /> F <br /> PHONE 3 <br /> 2ACILITY NAME <br /> /� <br /> C I ADDRESS <7 may. /' ' ,, I�: `�•l t�: ca r+ L••.. /}c. -- i <br /> ;, I CROSS STREET —�� 1 10 <br /> I I PHONE t I <br /> TI O'+lNER/ P£RATO !/•�� I �0 - ,'-!1 <br /> / E 11PHON (J 7- ,t, C! <br /> C I CONTRACTOR NAMEJ--,'7 L- <br /> 0 <br /> O f 1 l I CA LIC # j % I Ci:SS/a -. z/}`7s 7 <br /> N I CONTRACTOR ADDRESS f/J `���! �L - <br /> T I WOR.K.CCMP.# .: c 11�-[�/ I <br /> R I INSURER t%7? C� f r�C%Yi .� �'��, Tf/•7C� - <br /> A N <br /> C I OTHER INFORMATION <br /> PHONE # �� X '� C)%� ,� �✓1? <br /> O I <br /> R I PHONE �4 I <br /> --�II111I1I11IlflIllllllllllilllll TcfEMICALs STORED PRSlIOcsY DATE vsT <br /> nxKIas ,IsT>�LED <br /> TAMC If) r ; � ✓d" I <br /> I <br /> 39- <br /> 39- <br /> 39- <br /> 3 9- <br /> 4-39 39-34- 1 <br /> { 39- <br /> { <br /> 39- <br /> ?I <br /> 9 lllllllll Illllllli1lf11{ Illllllllllllllllllflllil{111111lI111lllllll111111f11111i11{III11f1lI111111U1� <br /> ?-ll1ii1111i111111ii111 I <br /> ! APPROVED _ APPROVED WITH C0:lDITION{S1 DISAPPRO'T'D { <br /> L I (SEE ATTACHMENT WITH CONDITIONS) ,. <br /> A ! DATE '- <br /> ,y 1 PLAN REVIEaERS NAME <br /> —llllllllillllllllllllt _� illlll K 1111 ll Y Iltlll'lllllliltlllllltlllflllilillilll{illllllll l! lllllllifillllllll{l� <br /> APPLICANT MUST PEREOR-M ALL 10RK IN ACCORDANCE A AN JOAQUIN COUNT`: ORDINANC3S, STATE LAWS, AND RUL.35 AND REGL7I.ATIONS CF <br /> SAN SOApUIN COUNTY PVF3LIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES T''E FOLLOWING: 'I C3P.TY:Y THAT IN <br /> ANY R5 N <br /> PLOY PE 0 UC <br /> T:.E PSRFORI`tANRKERFTHE S CCM�o:Y�SATOIONWHICH THIS LAWS OF CALIFORNT IS IA-'ESC4NTRACTOR SLHIRINUMQR o ONTRACTINGN3IGNATU? C� TI.'Y-cS THEgR AS To FOLLOWING: <br /> S'UBJ'ECT TO PE <br /> "Y CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR I THIS PERMIT I5 ISSUED, : SHALL EMPLOY PERSONS SUBJECT T_O WORKER'S <br /> CC14PENSATION LAWS OF CALIFORNI <br /> ITi3 <br /> //(/ J . � —a <br /> . ..•� - <br /> DAT <br /> A?PLICANT'5 SIGNATURE: T <br /> BILLING INFOP-MATION: <br /> indicate the responsible party to be billed for additional PHS-EHD staff time expended byod <br /> permit payment coverage per tank. If the party designated below is different than the permit <br /> applicant, e.g. property owner, the party must acknowledge this responsibility for the billing <br /> by signature and date below_ <br /> vi t"- '-"eadd s c -% ,/ hone number 7,02 (>�� � �� � ' <br /> Name f <br /> Signature <br /> EFT 23-0038 <br />