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ENV1nU-41,L14i„L "cNL0 UIVISION <br />r APPLICATION FOR UNP' 20UND TANK RETROFIT, TANK LINING, OR PIPINf 'AIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />TANK REPAIR/RETROFIT TANK LINING PIPIMr RFPAtR <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed/permit <br />ditional PHS-EHD staff time expended beyond permit payment coverage per tank. If the <br />party designated below is different than thapplicant, e.g, property owner, the party must acknowledge this responsibility for <br />the billing by signature and date below. <br />N <br />Mailing Address <br />EPA SITE # <br />PROJECT CONTACT & TELEPHONE #;ot) <br />F <br />FACILITY NAME �” <br />PHONE # <br />A <br />I <br />ADDRESS I q <br />c7 E <br />L <br />CROSS STREET n <br />T <br />OWNER/OPERATOR <br />PHO # <br />Y <br />-SONY L <br />C <br />CONTRACTOR NAME <br />HONE <br />0 <br />N <br />CONTRACTOR ADDRESS <br />CA LIC <br />CLASS <br />T <br />w <br />AINSURER <br />WORK.COMP.# <br />7 <br />C <br />OTHER INFORMATION <br />T <br />0 <br />PHONE # <br />R <br />111111111111111111111111111111 <br />by PHONE # <br />TANK ID # TANK <br />SIZE CHEM ALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- I — 1 <br />-6- vaJ L <br />T <br />39- <br />_ I L— L7 <br />A <br />39 <br />N <br />39- p <br />K <br />39- <br />39- <br />39- <br />P <br />III1 <br />L <br />APPROVEDTEE <br />PPROVED WITH CONDITION(S) DISAPPROVED <br />A <br />h, <br />TTACHMENT WITH CONDITIONS) <br />N <br />PLAN REVIEWERS NAME <br />1 111111111111111111111111111 I I I I II I I <br />DATE <br />I I I I I I I, 11111111 I I I I III i i l l l 111111 11111111111111111111111111111 <br />APPLICANT <br />MUST PERFORM ALL WORK IN ACCOR ANCE WITH <br />SAN•JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN <br />JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LT'CENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT <br />IS J'SSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.* CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK <br />FOR RICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />/ <br />APPLICANT'S SIGNATURE: 4 — �` _ <br />TITLE 4K -•t ✓l0 ,7 DATE r—l-� <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed/permit <br />ditional PHS-EHD staff time expended beyond permit payment coverage per tank. If the <br />party designated below is different than thapplicant, e.g, property owner, the party must acknowledge this responsibility for <br />the billing by signature and date below. <br />N <br />Mailing Address <br />