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'PLICATION _SR WD'_'RGROUNJ -:,.VK Rc-TROFIT. OR PIP!NG REPAIR PERMIT <br /> i <br /> T315 7ER).'1: =X?!QES 90 DAYS F RCM Tr A?PROV;,= DATE. DO NOT URM rN Ah. SHADED AREAS. I.NDICATE PERMIT:'!PE SMO1: <br /> _TA.YK R.r_OFIT PIPING REPAIR <br /> ' EPA SITS Y PROJECT CON'T'ACT s T£LEPSCNZ 9 ///;; "71, <br /> c _ACILI:Y NAti PHONEG...-y31- <br /> ADORESS V V h'v C' <br /> I `� <br /> :. I CROSS STREE.-- <br /> 1 <br /> S ' <br /> T 1 OWNER/OPERAa O.Z 1 PRONE i <br /> C CONTRACTOR NAME (' ( ?HONE 2 <br /> O 60' (.(l ({� I <br /> , C. / n <br /> N ( CONI'RAC.TORRFSS' I C1 LTC 2 I I CLASS µ <br /> T 0 oo <br /> /1 <br /> R I INSURER I WORS.COMP_ - OS( <br /> C I OTHER ZNFOR-AT=ON 1 ` <br /> T <br /> O I 1 PHONE 2 1 <br /> R , <br /> I I PHONE 2 I <br /> 1 TANK ID 9 ! T;'-Ca SIZE CHEMICALS STORED CORREMMY/PQEVIOUSL7 DATE VS: INSTALLED <br /> 1 39 <br /> T 1 <br /> 39- <br /> 39-_ <br /> 9-39- { I I I <br /> rr 1 39- <br /> 1 39- i I I <br /> 1 39- l I 1 1 <br /> 1 39- i ! 1 <br /> —il111{1fi1lfflillll{ll1!}liflll}l![iI1I1{IIIIIII}1{llllliI1iI11Illl{tIt1111.1111}It1II Willlll1111111111111111111111111{111111{1 <br /> Z. 11 APPROVED --V—/ APPROVED wrrA ObID2'=ON(s)k ' DISAPPROVED 1 <br /> 'SEE A UI7B ♦_ ONS) 1 <br /> V 1 ?LAN REVf'JERS NAME DATE <br /> -11111I1lflillillflItlltltilllititlltiiitllIlt{{!!!!l !i lif i 11111111!!I}1111111111![IIitlllillt![Illllll}III <br /> 1 <br /> 12?LICANF MUST PERFORM! ALL WORK Ari ACCCRDAVC- �ITli SAN JOAQUIN �_Omrrx O CES, STATE LAWS. AND RULES AND ZSCULkTIONS OF 1 <br /> 1 <br /> JOAQUIN COTANTY ?VBLZC HEAL:i S<"TtVICES. OR LICENSED AGEM'S SiG:7ATJAE CMrrIFIES THE FOLLOWING: -I THAT :,i � <br /> 1 <br /> S= PE_QFORfSANC= OF = rORK FOR :t2lICIi THIS ?= 522' IS ISSUED. I SFiAL[. NCC EMPLOY ANY P--RiON I?7 STiLTi A :BANNER AS'ill d£COME. I <br /> _—U!LnCT TO WORX--'Z'S COMPENSATION LAWS OF CAL_-:.'2NIA.` CONTRACTOR'S HIR::Vr- OR SOHCONIRACTING SIG.YA-.VRE CE.ZTIFIE; T3E FOLLOW'INC-_1 <br /> -! CIRTIFY TIZAT Z?+ THE PERFO -VCE OF THE WGRZZ FOR WHICH THIS PERMC IS ISSUED. I SHALL EMPLOY PERSONS SU3jECr� UORIcER'S i <br /> `JMPzNSATTON .AWS OF CALIF - <br /> ` �/J]y/�) 1 <br /> :.?PL7CANI"S SiGYATVRE: TITLE / i--' <br /> 1 <br /> 1.3%LUNG INFORMATION: 1 <br /> T-ndicate the responsible party to be billed for additional FHS-EHD staff time expended beyond <br /> ae-mit payment coverage per tank. If the party designated below is different than the permit <br /> applicant, e-q_ property owner, the party must acknowledge this responsibility for the billing <br /> by signature and date below. <br /> num <br /> 1 >- <br /> Nam Mess ber <br /> S-gna:ture- I <br /> !�:H 23-0038 <br /> i _ <br />