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01/08/97 15:06 rd0. 255 1;02 <br /> 01-17-29yb by• �seri rnu <br /> r APOLICATloN FOR UNDERGRaUNO TANK RETROFIT, TANK LINING, OR PIPING REPAIR P KHIT <br /> THIS PERMIT EXPIRES�00 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> i <br /> TANK REPAIR/RETROFIT TANK LINING PIPING REPAIR <br /> EPA SITE A PROJECT CONTACT i TELEPHONE <br /> F FACILITY NAME ��L S b PHONE A 'T..OtA (O <br /> A <br /> C ADDRESS <br /> I <br /> L CROSS STRUT WSm <br /> i <br /> OWNER/OPERATOR / 1 PHONE 0 <br /> T <br /> C CONTRACTOR NAM PHONE ! ) Qr <br /> a <br /> N CONTRACTOR ADOR S I —�` CA L t C 0t U CLAS; <br /> T YORK.COMP,N <br /> R INSURER tJ A v . 7- <br /> A <br /> C OTHER INF?4ATIoN <br /> i <br /> O PI(ONE M <br /> R F PRpiE tY <br /> 11111 tillllil�llli�ll!!tl!!t <br /> TANK 0 * TANK SIZE CHEl4ICAL5 STOR 0 CURRt?NiLT/eREVIOUSLY OATS UST INSTALLED <br /> 39- <br /> ? 39 <br /> A 3 . <br /> N <br /> K � <br /> I <br /> 1 � <br /> P k <br /> L APPRUVED APPROVED WITH CONDITION(S) Dt>;APPROYEO <br /> A �'AYTAC"XT YITN C=ITIONC) <br /> N LAN REVl6V6RS NAME, � / ` LATE <br /> 111tit1tfltlllittli if1f1 1 f litllintt 11111f <br /> AP ICANT MUST PERFORM ALL WORK IN ACCOROP&M WITH SAN JOAQUIN COUW" ORDINANCES, STATE LAWS, AND AULES AND REGULATIONS OF <br /> I SAA JOAQ,)IN C"TT PUBLIC HEALTH SERVICES, OtA X OR LICEXM AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFT THAT IN <br /> Tki PERFORMANCE OF THEIWORK FOR WHICH THIS PERMIT IS ISSLIEO, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SV ECT TO WORKER'S COOINSAT10N LAWS Of CALIFORNIA." COORACTOR'S MIRING OR SLJ =TRACTINO SIGNATURE CERTIFIES THE FOLLOWING: <br /> "! CERTIfT THAT IN THEIP ORMANCE we WORK FOR WHICH THIS PURIT IS ISSM, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> iCOPENSATION LAWS OF 4L F N1 " <br /> i <br /> APF ICANT'S SIGNATURE: <br /> TITLE 'r � L DATE <br /> �Q <br /> i <br /> 31LLIMG I FORI4ATIONs ` <br /> Inditate the esponsibtt Darty to be blued for tdditloneL PNB•fH0 ttsff time expv4ed beyond permit payment coverage per, tank. If the <br /> Dprty d'e% tretov is�difftrtnt than the permit applitant, e.g. ps wetly owner, the party tsswe acknarladge thda responsibility for <br /> rhe biil'inq by ipruture and date bekou. <br /> flailing Address <br /> lay Rhone Nuder ( 1 <br /> ;iynitUrt <br /> i <br /> i <br /> ik 1 <br /> 1 <br />