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:NY -- —i-IIIill'JM CN <br /> r APPLICATION FOR UP 'ROUND TANK RETROFIT, TANK LINING, OR PIP1N' ')AIR PERMIT G�"'7 <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE 1N ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> TANK REPAIR/RETROFIT _TANK LINING _ PIPING REPAIR <br /> EPA SITE I PROJECT CONTACT b TELEPHONE 9 <br /> c FACILITY NAME \C S<< ( PHONE <br /> A <br /> C ADDRESS <br /> L ( CROSS STREET <br /> I i ,\�� wv <br /> T OWNER/OPERATOR I PHONE <br /> C CONTRACTOR NAME PHONE '1 <br /> 0 T C�•r.�. r� <br /> N CONTRACTOR ADDRESS CA LIC # CLASS <br /> R INSURERWORK CCMP +� <br /> A .� Li` <br /> 8�1�i l 017 <br /> C OTHER INFORMATION <br /> T i <br /> 7c.,2�� \ �r � I PHONE # Lo> — ,3 --> <br /> PHONE 0 <br /> I l f I I 1111111111111111111111111 <br /> TANK ID X TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> T 39- 2A 39- <br /> N 39- <br /> K 39- <br /> IIII <br /> i P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A -<- ATTACHMENT(SWITH CONDITIONS) <br /> N PLAN REVIEWERS NAME__��� /q rTAiFY l DATE <br /> i III(illlilllll11f1111111111IIIII 111111111111 111111 111!!! II!!llllllfll I1T�111111T11lill 1111111llIIlII111111 01Ili! <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 /> I THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON 1N 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 /> APPLICANT'S SIGNATURE: �"� '� TITLE Q 7~C � cw-K G DATE D' <br /> I .I� <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS---HD staff time expended beyond perait 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 pcQ`p 'ipll <br /> Mailing Address Lk t �t�v�� f_ �lti �Cti�vY�c� C;-, gcI(.o �3 <br />