Laserfiche WebLink
ENVIRC,NMENTAL HEALTH DIVISION ._. <br /> APPLICATION FOR UNDEAftmOUND TANK RETROFIT, OR PIPING REPAIR PERMIT r� <br /> THIS PERMIT EXPIRES 40 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATZE PERMIT TYPE BELOW: <br /> TANK RETROFIT PIPING REPAIR <br /> EPA SITE PROSECT CONTACT G TELEPHONE <br /> = =AGILITY NAME1PHONE I <br /> A I� V .t <br /> cI ADD�Q-2-2 �'����C Ad, e,,;n� CA. SS 3G6 <br /> jI CROSS STREET / �r / C1 - <br /> T I OXNER/OPERATOR I PHONE <br /> C I CONTRACTOR NAME )1 PHONE r <br /> D , t.l _e rLra J�nL� ��� <br /> N } CONTRACTOR ADDRESS (30K CA LIC 0 <br /> R I INSURER 11 L'.6.CI I WORK.COMP-tF �V��C SVFG 3474_~0�_- E <br /> C I OTHER INFQRMATION r" felts, : 26 UcSf 61e.&,--d FiLdeek CA %J101 <br /> PHONW 4 <br /> a I <br /> PHONE <br /> �IllllillllTA,NK1111i1111111lI1� <br /> TAPJK 1 a TANK SIZE Gi3MICALS STORED CURRE.uTLY/pREV'aDCSLY DATE UST INSTA:.LED � <br /> 1 39- �fllr� 14rc„��57 S2 a, i1 ..� - I --- - I <br /> 1 39_ <br /> A I 39- -- <br /> N I 39- I I <br /> I <br /> j 39- 1 I <br /> �1111111lllilllllllll1111i11 llt 1111111111111i111[I 1111illlilllll1111111tlltlllilllllllllllll11111111Il1llllll1111111i1l11lIII <br /> L I APPROYED PPROVED ATH CONDITION M DISAPPROVED <br /> A I WITH CONDITIONS] ! <br /> N ! PLAN REVIEWERS NAME <br /> DATE <br /> A III III IIIIIIII111111Aillllllll 11111 Ililll l IIIIIIIl1111llltllilllllllll111[liilllil 1111 illllllli{lltillllll <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN CCU:1'.Y ORDIN3..'3CE5, STATE CAWS, A.YD R[;.,ES AND REC:JL.ATIONS CF <br /> SAN JOAQUIN COUNTY P�IJBL:C HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT :N I <br /> "E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A "BANNER AS TO BECOME <br /> SUBJECT TO WORKER'S CCMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:' <br /> "I CERTIFY THAT IN THE ?ERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, i SHALL EMPLOY PERSONS SUBS--CT TO WORKER'S <br /> COMPENSATION LAWS OF CAL:FORN 6 <br /> TITLE N CY-DATT <br /> APPLICANT'S SIGNATURE: <br /> BILLING INFORs'ATION: <br /> Indicate the responsible party to be billed for additional PHS-FHD staff time expended beyond <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 /> Name jj'KCo uut /'� 6d ess �C� I1 Phone number4 <br /> S ignattxrt <br /> - A!t � �, - te �- Lees h� <br /> EH 23-0d 8 <br />