Laserfiche WebLink
t ENVIRCNMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGRCI. 14K RETROFIT, TANK LINING, OR PIPING REPAID AMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE 3ELOW: <br /> TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br /> EPA SITE I PROJECT CONTACT & TELEPHONE <br /> F FACILITY NAME <br /> A PHONE 337 <br /> C ADDRESS <br /> [ ' <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE <br /> Y V -:2 1 <br /> CO CONTRACTOR NAME IV PHONE 0;-6 <br /> Q c _46,1 - 3 3 7 <br /> N CONTRACTOR ADDRESS JC W CA LIC OQ 7 CLASS <br /> T <br /> A INSURER Q 8 ,J`�3 WCRK.CCMP.9 <br /> C OTHER INFORMA ION O <br /> T <br /> 0 PHONE <br /> R <br /> PHONE <br /> 111111111111111111111111111!II <br /> TANK ID » TANK SIZE I CHEMICALS STORED CURRENTLY/PREVICUSLY DATE UST INSTALLED <br /> 39- I0 0 O C, %-c,--1, <br /> T 39- L ' <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P rfl-ffl-[-ffff 111111111 E 1111111111111111111111 1111111111111111111111 <br /> 1111 <br /> L APPROVED APPROVED WITH CCNOITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) J <br /> 4 PLAN REVIEWERS NAME DATE <br /> 111111111111111111lllilllllllllllillillllllll 111111111 Illlllllllllllllltll II II1111111111111111 111111 I 111111111i1111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOACUIN 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 CCMPENSATICN LAWS OF CALIFORNIA." CONTRACTCR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO 'WORKER'S <br /> CCMPENSATION LAWS OF CALIFORNIA." n <br /> APPLICANT'S SIGNATURE: TITLE I DATE <br /> 3ILLING INFCRMATION: <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the <br /> party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br /> the billing by signature and date below. <br /> Name <br /> Mailing Address <br /> Day Phone Number ( ) <br /> Signature <br /> '' CA C—L LA ADV ACJ c.0��_ YN 5 <br /> EH 23-0038 <br /> Ad I <br />