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ENV111-1--L11i,.L uLALI,I uIv1SICN APPLICATION FOR UNI' 'OUND TANK RETROFIT, TANK LINING, OR P1PINr 1AIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: _TANK REPAIR/RETROFIT TANK LINTMn oro nit 1c-- BILLING INFORMATION: Indicate the responsible party to be billed for additional PHS-EHO 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 date below. Name U C—, Tom`/ ,�N l N Mailing Address_ ic7% L4 , i;�t2✓9 0T- �� (� ,I v �� y ��16 r GETTLER - RYAN INC. DENNIS GAN Construction Supervisor Direct (510) 551-7444 Ext. 240 6747 Sierra Ct., Suite J Business (510) 551-7555 Dublin, CA 94568 Fax (510) 551-7888 SITE # .4 334�(Z PROJECT CONTACT & TELEPHONE # J)ENn1�S FLITY NAME EADDRESSJ)VTr PHONE # J�,\�/ 1 CSZ, L I CROSS STREET f� Y T OWNER/OPERATOR PHONE # Y iZ- ",— o- C (It 4 6 Z� C p CONTRACTOR NAME � �L� 1(nl I ,tiL PHONE # SI !✓' S5� -7SS TCONTRACTOR ADDRESS 6'1 �1 CW -2A �� (� J BL CA LIC # ZZv-793 CLASSL 17 A —INSURER C 4Lr% o,eN)A CL -y2" iV52 t', %i�� 3. -'Z A/� Gtl WORK.COMP.# 4u 21, `I 3 t C OTHER INFORMATION T 0 PHONE # R llllllllllllllllllllllllllilll PHONE # TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED T 39- A 39- 9 N N 39- 9- K 39- 39- 39 -39- 39- L L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED A ( (SEE FTACH ENT WITH CONDITIONS) N PLAN REVIEWERS NAME \ LDATE I I T ! I I I LAWS, I AND APPLICANT MUS' PERFORM ALL WI6R�! NI ACCORD CEI [ H SANT OAOUI N COUNTYI ORDINANCES, STATE RULESI ANDI REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 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 SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "! CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: K'ytc� D f�Cy TITLE DATE BILLING INFORMATION: Indicate the responsible party to be billed for additional PHS-EHO 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 date below. Name U C—, Tom`/ ,�N l N Mailing Address_ ic7% L4 , i;�t2✓9 0T- �� (� ,I v �� y ��16 r GETTLER - RYAN INC. DENNIS GAN Construction Supervisor Direct (510) 551-7444 Ext. 240 6747 Sierra Ct., Suite J Business (510) 551-7555 Dublin, CA 94568 Fax (510) 551-7888