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1,CAL111 UIVISION <br />APPLICATION FOR 1 tGROUND TANK RETROFIT, TANK LINING, OR PIP fEPA1�MIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />_TANK REPA R/RETROFIT 1_TANK LINING PIPING REPAIR <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional PHS-EHO staff time expended beyond permit payment coverage per tank. If the <br />party designated beton is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br />the billing *2 sAnyature and date brl,k. <br />Name <br />Mailing Address 5-30 <br />n <br />EPA SITE 0 <br />PROJECT CONTACT & TELEPHONE # ' <br />AFACILITY <br />NAME <– 1 _ <br />PHONE # <br />C <br />ADDRESS1� <br />L <br />I <br />CROSS STREET <br />I� <br />T <br />OWNE OPERA <br />PHONE <br />Y <br />DA <br />C <br />0 <br />CONTRACTOR NAME <br />rC <br />iG� STA i7t -' <br />PHONE <br />TCONTRACTOR <br />ADDRESS ?'O <br />CA LIC # 3c)y <br />CLAS <br />U <br />z - <br />R <br />A <br />INSURER <br />WORK.CCMP.# O <br />C <br />OTHER INFORMATION <br />T <br />0 <br />PHONE # <br />R <br />IIllilllllllllllllllllllllllll <br />PHONE # <br />TANK 10 # <br />TANK SIZECHEMICALS STORED CURB NTLY/PREVIOUSLY DATE UST INSTALLED <br />39- Q <br />/D, Oct �C�[J•t%� <br />��1�1�`�ii7 <br />T <br />39- <br />- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P <br />II11 <br />L <br />APPROVED APPROVED WITH CONDITION(S) <br />DISAPPROVED <br />A <br />N <br />PLAN REVIEWERS NAME <br />(SEE ATTACHMENT WITH CONDITIONS) <br />I l I I III IIII III III V I I I ITIlTi <br />_7 l riQ� <br />111111 111 1 1 1 1 1 1 TTI l 1111111 111 111 1 111111111171 <br />DATE <br />1111 I! 111111111111111111 111111111 i <br />APPLICANT <br />MUST PERFORM ALL WORK <br />IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE <br />LAWS, AND RULES AND REGULATIONS OF <br />SAN <br />JOAQUIN COUNTY PUBLIC HEALTH <br />SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES <br />THE FOLLOWING: "I CERTIFY THAT IN <br />THE <br />PERFORMANCE OF THE WORK FOR <br />WHICH IS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON <br />IN SUCH A MANNER AS TO BECOME <br />SUBJECT <br />TO WORKER'S COMPENSATION <br />LIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING <br />SIGNATURE CERTIFIES THE FOLLOWING: <br />"I <br />CERTIFY THAT IN THE ERFORM <br />CE 0 HE WOR WHICH THIS PERMIT IS ISSUED, I SHALL <br />EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CA FORNI <br />" <br />APPLICANT'S SIGNATURE: <br />TITLE <br />DATE <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional PHS-EHO staff time expended beyond permit payment coverage per tank. If the <br />party designated beton is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br />the billing *2 sAnyature and date brl,k. <br />Name <br />Mailing Address 5-30 <br />n <br />