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3 � <br />ENVlhlnu1L'1r,1L IILrILIII DIVISION <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT URITE 19 ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />_TANK REPA R/RETROF TANK LINING PIPING REPAIR <br />BILLING INFORMATION: <br />Indicate the responsible party to be bitted for additional PNS -END 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 'Xy,sjInpture and date brrA. <br />Name / &(Z Cd <br />Mailing address -:5-30 <br />i�n <br />EPA SITE U <br />PROJECT CONTACT b TELEPHONE <br />F <br />A <br />FACILITY NAME �' j <br />1` <br />PHONE '�• y` <br />F <br />C <br />ADDRESS <br />rr <br />�� <br />I <br />1� �r %=CCS •� _ 2 -? <br />L <br />1 <br />CROSS STRE�.L�• <br />Y <br />OPERA <br />/ p <br />� Cjuv < `9z <br />(J! <br />OWNS <br />C <br />CONTRACTOR NAME—..,..PHONE <br />sT�i�G/I <br />0 <br />Ick -,�,��J• <br />N <br />CONTRACTOR ADDRESS <br />CA LIC <br />CLAS <br />�— <br />T <br />J <br />R <br />INSURER <br />— _ <br />WORK.COMP.;v / 9 <br />A <br />C <br />OTHER INFORMATION <br />T <br />0 <br />PHONE I <br />R <br />IIII111111111111111111((111111 <br />PHONE J <br />TANK 10 X <br />TANK SIZE CHEMICALS STORED CURB NTLY/PREVIOUSLY DATE UST INSTALLED <br />39 <br />yc�G �LLO/`� <br />Z'07' <br />T <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />i l i <br />1TIr T1T 1-(71TI-ITiT1llITITTT]T <br />P <br />L <br />APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />A(SEF <br />N <br />PLAN RE/[EWERS NAME <br />Illllllll11I111111111II I1 111 <br />ATTACHMENT WITH CONDITIONS) _ <br />L% �DATE <br />II TTf11111111� II1T if 11111111111111111111111111111111111111111111111illllllilll7 <br />APPLICANT MUST PERFORM ALL WORK <br />'"lllill <br />IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH <br />SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT 1.14 <br />THE PERFORMANCE OF THE WORK FOR <br />WHICH ,IS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION <br />ALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I <br />CERTIFY THAT IN THE PERFORM <br />CE 0 HE,WOR R ICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CA FORNI <br />APPLICANT'S SIGNATURE: <br />TITLE DATE <br />BILLING INFORMATION: <br />Indicate the responsible party to be bitted for additional PNS -END 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 'Xy,sjInpture and date brrA. <br />Name / &(Z Cd <br />Mailing address -:5-30 <br />i�n <br />