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8-2S-1998 3:S8PM FROM P. 3 HNVIAONME]ITAL WEALTH DIVISION " ' APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERNIT L/ TH Lti PERMIT EXPIRES 90 DAYS FACM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PE9NIT TYPE HEGOW: I/ TALAR a(yie+D RBPwIQ 11'' I EPA SITE R I PROTECT CONTACT 6 TELEPHONE M pLrM lC-F�J[-''; 1 p ZS 4Oa2 I F I FACILITY NRNP 1 YOB VT-0 Q 1 Ck---5 6M��I I PHONE 9 / joq) gST6L-� (z5& I Ii ADDRESS L I CROSS STREET Y710.A�GlM. �� _ { Y i ONNER/OPERATOR 1 PHONE » T / (Igzf) 8p �2-gooZ VI CONTRACTOR NAME SGi[Y'O�A+��O wl�C.y.� �hL I PEON£ k ///6) i -5 — Z/716 i�/�-I' N I CONTRACTOR ADDRESS ZSD�t.1�C. �qG� I CA LIC N 50^L 3 77 lit C 'S A' BOIL DTo, Ph-% o 1 R INSURER FGGlk:,1 i HDRE.COMP.t A 1- G I C I OTHER INFORMATION I I T O I I PHONE N Q r I 1 PHONE H I111111111TANK 1Illlllll11111 _ r 19 L TAN)( in / t \2- pp C, i CHEMMCl $TOR CURAFS!}'LY.P (�USLY i DATE lGET qq O Az.i,ED I TI 39- 'L ^ i;..- a 000 I ow- It O 1a O iz. 000 14`10 N 1 39- 39- 39- 9-19-I9- f I I 1 I9- ! I I I �I11111111111111t1II111111111111tltllltlt1111111111{iIIllttlllttll1111111111111111111t1tttllltt1tI11111I111111111111111I11111111 L 1 APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED 1 A 1 / (SEE ATT� WITR CONDITIONS) N I PLAN ARVIEWERS NAME OAT, DATE - i - �tltlllglllll111111111111111111111 1llttllt11t111itII1111111111II11[[I1f11111111111111111111tlt11111tllllllllllllllllllf1111111 APPLICANT MUST PERFORM ALL ROHR IN ACCORDANCE WITH SAN JOAQUIN COUNT) ORDINANCES. S'L'ATE LAWS, APO ROU'-_" AND REGDLATIONS OF { SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT-S SIGNATURE CERTIFIES THE TOLLOWING: •I CE%TZFT T2AT IN I THE PERFORMANCE OF THE WORE FOR W CH THIS P£RNIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO EECCME I SUEJECT TO WORRFR'S COMPENSATION LAWS OF CALIFORNIA,- CONTRACTOR'S HIRING OR SUBCONTRACT_NG SIGNATURE CERTIFIES THE POLLOWING:I •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH IS PERMIT is ISSUED. I SHAIJ. EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.- APPLICANTS SIGNATURE: TITLE 0;6 DWT` ILLING INFORMATION: ndicate the responsible party to be billed for additional PHS-EBD staff time xpended beyond permit payment coverage per tank. If the party designated elow is different than the permit applicant, e .g. property owner, the party ust acknowledge this responsibility for the billing by signature and date elow. l ame V address ll 7 ac(�hone number 1707 765-- I �d _ ignature H 23-0038