Laserfiche WebLink
ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNOERGRCUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN AHY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _TANK REPAIR/RETROFIT _TANK LINING P ING REPAIR <br /> EPA SITE 1 PROJECT CONTACT & TELEPHONE <br /> F FACILITY NAME / Q <br /> A PHONE S G)/ � � 2,313 <br /> C ADDRESS J 1 <br /> I <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR <br /> Y PHONE <br /> C CONTRAC70R NAME 0 + PHONE <br /> 0 (� <br /> N CONTRACTOR ADDRESS CA LIC CLASS / <br /> T � � � - <br /> R INSURER / ? /, ; <br /> TCO <br /> ' ' '� �OBy�' WORK.C^.MP. C� <br /> THER INFORMATION <br /> PHONE <br /> llilllllllllllltllllllllll[1 PHONE it <br /> 39- <br /> TANK ID TANK SIZE CHEMICALS STORED CURRENTLY/PREVICUSLY DATE UST INSTALLED <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> -1111111111111f <br /> a <br /> _ APPROVED APPROVED WITH CCNDITION(S) _ DISAPPROVED <br /> (SEE ATTACHMENT WITH CONDITIONS) <br /> q PLAN REVIEWERS NAME DATE <br /> tllil111111111111Iltllilil111I1111111111111!!ill 1111!11 11111111111111111111 II 111111111Illil1!!l11111111l1li111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTCR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PE. RMANCZ OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WCRKER-S <br /> COMPENSATION LAWS OFL <br /> NIA." <br /> APPLICANT'S SIGNATUR /e. TITLd ATE 7 v'"`-' <br /> LING INFORMATION: <br /> icate the responsible party to be billed for additional PHS-EHO staff time expended beyond permit payment coverage per tank_ If the <br /> ty designated below is different than the permit applicant, a-g. property owner, the party must acknowledge this responsibility for <br /> billing by, ignature,�nd date below. <br /> e L � <br /> I i ng Address <br /> Phone N r <br /> iature - <br /> 3-038 <br />