Laserfiche WebLink
APPLIC4TION -SR TANK. RZTROFIT_' OR PIPING REPAIR PERMIT <br />T:iIS 7ERMI: =X3: QES 90 DAYS FRCM TFE A7PROV:.= DAT'', DO NOT WRITE IN AN SHADZD AR AS_ INDICATE PERMIT TYPE 9SL0A: <br />EPA SITZ X <br />F FACILI. Y MAX- <br />CROSS <br />A - <br />CROSS STREET <br />z <br />�- k OWNER/OPERATOR <br />v� <br />C 1 CONTRACTOR Na1-FE <br />d <br />I: CONTRACTOR :.DORES <br />T <br />R # INSURER <br />A <br />C k OTHER INFORMATION <br />T <br />4i <br />R <br />V <br />_TP -2K a- -Or IT PIPING REPAIR <br />PROJECT CONTACT L <br />PHONE I ' N YJ <br />rf <br />PHONE <br />�CACLAS�SS4 <br />i WOR'(_ COMP _ 7 <br />PHONE a <br />k i PHONE 2 I <br />TIf f1f1/1■f1I1 tl;flll� fa11■ <br />�fifltter■f1■1]■ ,tt ,,11>„>,1� <br />TA.vK. ID Ts T:,.v:; SIZECHLHICa7.S =RED CZ3RFENTLY/PREVIWSL-( DATE UST INSTALLED k <br />-T 1 39-- <br />A <br />9- A ] 19- <br />N ] 19- <br />x 1 19- l i i <br />39- <br />�]II]1]IllI11llli11111111111]11113[Illllllllllllil llilllilllliilllltlllll#dl�.Ell]Ilillllillllilllllllilllllilfllllill]Ilfllj <br />] APPCOVED APPROVED NI I==ON(SS DISAPPR9VE6 ]i <br />]- :7 pND2'IIONS) ] <br />,I ] PLA.`[ REVIE".7ER$ TAME M 00 DATE Az <br />---A 11111111lllllill1111iIII III till rITF11711IIIII f If1141 1Il1I 111111111111li1IIIIIIIIIIIIIIIIIIIIIII II Im IIIIII III IiIIIIII <br />A2PLIC.ANT KUs PERFORM ALL WORK IN: ACCCRAANCE -.;a:H SAN JOAQt'IN COUNT -1 O7DItiANC£S, STATE TAWS. AN'J RULES :S1n .REGULATIONS OF � <br />SAN JOAQUIN COUNCY PUBLIC HFa.L:_3 SZRVICSS, C NZR OR LIC£NS,:D Aczw,S SZISNAT"JRE C_RTIFIES THE FOL: -OWING: 'I C�tT11- THAT IIs i <br />PERFORMANCE OF TIM WORK FOR -71UCH THIS PF-ZAIT ZS ISSUED, I SFihL[. NOT c-?7PIAY ANY PERSON T;7 SUCHA .`SANNEA AS TO aECOHE i <br />SUBJECT TO WORKS -4'S COMPENSA I v LAWS OF CALFCRNIA.- CONTRACTOR'S HI2TVG OR SUBCONCM- CTTNG SIGNATURE CERTIFIES TAE FOLLOWINC:1 <br />r CERTIFY T`-- I:1 THE PERF NCE OF THE WGRX FO WHICH THIS PERMIT IS `ISSUED, L EMPLOY PERSONS SUaJECT -0 YORKER'S I <br />CAMPF.$ISATION :AWS OF CAL12 I I <br />:--7PI.I CAVI -'S SsGYA7"URP; TI E ,I /, <br />B !LLING INFOAMATZON- <br />I=ndicate the responsible party to be billed for additional PHS -EBD staff time expended bevond <br />pe -mit payment coverage per taxdk- If the party designated below is different than the permit <br />applicant, e -q- property owner, tae party must acknowledge this responsibility for the billing <br />',ay si n fta�:edatelow. <br />Namres phone numberS ignature <br />EH 23-0038 <br />8 - 0j,41 <br />f 6/zg�2. <br />