Laserfiche WebLink
f <br /> � E.WIRONME'„AL HEALTH D:ViS:CN /r/L/GAJ <br /> APPLICATION FOR UNDERGn-.,ND TANK RETROFIT, OR P:?ING REPAIR PE:LMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE :N ANY SHADED AREAS. INDICATE PERMIT TfP= BELOW: <br /> _TAMC RETROFIT PIPING REPAIR <br /> EPA SITE # PROS"_'C:' CON-,ACT 4 T....EPHC:IE # lJN\S 6ALLA\"-Ak3 333-(o ab <br /> F FACILITY NAME U t�p A L Sin ,,1Gr_ i-,c�, ct� /� PHONE x zpCt- O �U <br /> I I ADDRESS 'I / / • fes ` 4�� jiL � <br /> L I CROSS STREET <br /> I L�-tS�i I <br /> T I OWNER/OPERATOR I PHONE # <br /> Y <br /> OI CONTRACTOR NAME PHONE # AI <br /> TI CONTRACTOR .ADDRESS wA� ?)�l� e, I CA LIC # /„�DO -y/_ I CLASS[,( ^arc-lD'Tr T+ZMn <br /> R I INSURER T. I.L, ✓�"c l�i� 1J `tel `Y I WOR/KI.aCCMP.#!21�1'�G✓l1'L > ZZA-OD l3Qj- 1-l <br /> A <br /> C I OTHER INFORMATION <br /> T <br /> 0 I I PHONE # <br /> R <br /> PHONE # <br /> I <br /> IIl111111111111111111111111111 <br /> TANK ID # I TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I =A-' UST INSTALLED <br /> ! 39- 1 I D, 006 G Drt_ • ► ilk, .GA-�F�,�_ A-S��-ll�l� I SEPT, (-1156 <br /> T I 39- I Z .00 b 6 A--- - I 'Dl S L- I .6 <br /> A l 39- 353$ I o I__ -D(Es�L�- I sE,Pr.� "91 04- <br /> N ! 39- 1 z',00 CA/kL_ I 1AJhSTG C�IL�. I 5t_PT•� IG1gS <br /> K I 39- <br /> 39- <br /> 39- <br /> L <br /> 9-39 L 1 APPROVED APPROVED WITH CC:7DIT:CN(S) DISAPPROVED 1 <br /> A 1 �+ (SE�AT,*�C?r1•tE.YP ifITH CO."IDIT:ONS] <br /> N I PLAN REVIEWERS NAME �(/ �IIC� � DATE _ ��/11 �lg 1 <br /> —�IIIIIIIIIIIIIIIillllllllillllilllllllllllll 11111 I I IllllllilllllilllllllilllillllllllllllllllllllllliillIllllllll Mill 1111 <br /> APPLICANT MUST PERFORM ALL :FORK IN ACCORDANCE WITH SAN JOAQUIN COU!17! ORDINANCES, STATE LAWS, AND RULES AND ?=GULAT:ONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: : CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANN-ER :S TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERT:-:-7S THE FOLLOWING:I <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS'ISSU--.D, I Si-ALL EMPLOY PERSONS SUB,:--=7 TO WORK=Z'S <br /> CCMPENSATION LAWS OF CALIFORNIA." <br /> �� I <br /> APPLICANT'S SIGNATURE-� � � �l YSL�,� TI�E I-v�7� �� 0 1Z•'I tO <br /> J I ! <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-EHD 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 bill-J= <br /> by signatureanda��nd�� date below. <br /> Name LC �,( addressQO 14x3� LA Ione numn er r�zt,33 3 '(on13D ,�&Ct0 <br /> Signature <br /> 1 <br /> EH 23-0038 <br /> 1 <br />