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tNV1w-4,---L- "C.Lin UIV1SION <br /> 1 APPLICATION FOR UNDEi IND TANK RETROFIT, TANK LINING, OR PIPING 'R PERMIT <br /> t <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 8 TELEPHONE At <br /> AFACILITY NAME C SC <; PHONE <br /> C ADDRESS <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR \ n PHONE <br /> C CONTRACTOR NAME .ham PHONE 9 <br /> 0 <br /> N CONTRACTOR ADDRESS .) <br /> �.l Qo n L ` L D CA LIC i! �S�4`\ CLASS - Co <br /> T <br /> AINSURER A�� � / L WORK.COMP. �r, $G� C�C� OS <br /> C OTHER INFORMATION C����_ .i�c��� �� \ fA <br /> T `W-� <br /> Rz,T\ O \� \� �� PHONE <br /> PHONE I <br /> 111111111111111111111111111111 <br /> TANK ID X TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- L ��3 ,. &I VWf"M-z,r" <br /> T 39- <br /> A 39- <br /> N 39 <br /> K 39- <br /> 39- <br /> 39- <br /> 111111111111111111HUTrM MR11111111111111 <br /> L APPROVED 0 <br /> APPROVED WITH CONDITION(S) DISAPPROVED <br /> A -?SIE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME e/L 7,-a e,E* DATE <br /> 11111111111111111111111111111111i11i1111111 II 111T IIIIT II111! II III 111 I i I I 11!111 IIIIIIiII! 111111 lllllllllll <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN 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." 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 CAL!(OR A." <br /> I , L 'VA <br /> APPLICANT'S SIGNATURE: / TITLE N�r-C-T 'k krxoSyL DATE <br /> BILLING INFORMATION: <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 fg—(-O <br /> Ma i t i ng Address 12d� ���t�� 1,7)I-_ �� �v�`W,4k <br />