Laserfiche WebLink
ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGk- .0 TANK RETROFIT, TANK LINING, OR PIPING REF PERMIT <br /> THiS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE iN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> TANK REPAIR/RETROFIT _TANK LiNING PIPING REPAIR <br /> EPA SiTE # PROJECT CONTACT & TELEPHONE # Alk7 <br /> F FACILITY NAMEI r'/o � �J� �! (� 9 PHONE # <br /> A <br /> C ADDRESS 130 <br /> I <br /> L CROSS STREET <br /> Y OWN R/� R PHONE # <br /> C CONTRACTOR NAME " —r 1 I�Cf �j�r L, PHONE # C _ (O (�� 19 Q� <br /> N CONTRACTOR ADDRESS CA LIC # / '30,50 CLASS r <br /> R INSURERV�r WORK.COMP.# �w O 73 ,02. <br /> A <br /> C OTHER INFORMATIOiI <br /> T <br /> 0 PHONE # <br /> R <br /> PHONE # <br /> TANK <br /> IIIIIIIIII1IIIIIIIIIIIIII <br /> TANK ID # TANK SiZE CHEMICALS STORED CURRENTLY P EVIOUSLY DATE UST INSTALLED <br /> 39-T 39- L 7 —a <br /> A 39 <br /> K <br /> 39- <br /> IIIIII III iTTI(Hi-II-II 1114111 1if]11i1111111111111111111111111 IIT(1T1(Tiillii(IIii1Tii1TTTiTTiTTTiHT fiTffiTTTfiTHTTiTHT <br /> P ,jG.. <br /> L APPROVED APPROVED WITH COND(TION(S) DISAPPROVED <br /> A % (SEE ATTACHMENT WITH CONDITIONS) -1 <br /> H PLAN REVIEWERS NAME � �L' <�. DATE /- __ <br /> 111111111111111111111111111�IlilllllTll Iff IV11111(IT11111i1iIIIIR!HiiiIHiT11111llilIIIIIIlTil11ffil IIIII11il1Tllilil <br /> APPLICANT MUST PERFORM ALL WORK iN ACCORDANCE 'a1TH SAN JOAOUiN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUTN COUNTY PUBLIC HEALTH SERVICES. 01.'NER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THiS PE.."IT iS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATiON LAWS OF CALIFORNIA." CONTRACTOR'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 /> COMPENSATION LAWS OF CALIFORNIA." <br /> r <br /> APPLICANT'S SIGNATURE:—=—c r � TITLE 146 �p! DATE <br /> BILLING INFORMATION: <br /> indicate the responsible party to be billed for additional PHS-END staff time expended beyond permit payment coverage per tank. If the <br /> party designated below is different than rhe permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br /> the bitting by signy ure and date belo _ <br /> Name r/e if C /6f-( __ c2L�/���Jr�'✓' G) <br /> Mailing Address r r r <br /> Day Phone Number <br /> Signature <br /> EH 23-0038 <br /> I ' 1 <br />