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ENVIRONMENTAL HEALTH DIVISION I.PPLICA'TION FOR UNDERORL•OND TANK RETROFIT, OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APrPROVAL DATE. DO NOT WE= IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW; _TANK RETROFIT PIPING REPAIR EPA SITE p PROJECT CONTACT A TELEPHONE 0 r- � FACILITY NAME A Gas= w s= NND `PHONE p (� iI ADDRESS LJ./1. �� 1 1 n _j.,� L I CROSS STREET ��`Y\1�(/� I TR/OPERATOR I PHONE 0 , Y C CONTRACTOR WANE r rr PHONE p 6 O - 33 N I CONTRACTOR ADDRESS T C�J�1 v 1 R INSURER /' I WORK.COMP.p A C I OTHER INFORMATION T 0 PHONE p I R IIIIIIIIIIIIIIIIIIIIIIIIIIIIIII I PHONE p TANK ID p TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- L T 39-_ I I A 39- N 39- K 39- 39- I 39- P L APPROVED !APPROVED WITH CONDITION(S) DISAPPROVED I: A SEE ATTA ENT WITH CONDITIONS) N PLAN REVIEWERS NAME F. DATE �J PLICANT MOST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAM JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUEJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWINGI •I CERTIFY THAT IN THE PERFORMANCE O {oRs EngWHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OFPORN 11 . 1/3 APPLICANT'S SIGNATURE: _ TITLE .�_vT `�N2 DATE BILLING INFORMATION: Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and datebelow. Name'�}C-A 3? - w4ddress2 hone number 2D x-51 4' Sr-Y 001 Signature EH 23-0038 ,✓/ -