COMPLIANCE INFO_1986 - 1997 - Laserfiche WebLink

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a ENVIRUNMENIAL HEALTH DIVISION t APPLICATION FOR UNC )UND TANK RETROFIT, TANK LINING, OR PIPING 1R PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: r _TANK REPAIR/RETROFIT _TANK LINING X, PIPING REPAIR EPA SITE # r; -3 PROJECT CONTACT & TELEPHONE it F FACILITY NAME / X G. v PHONE #. G, _ L.s -3� 9 Z A 4f-14 C ADDRESS I L CROSS STREET / h I c. T OWNER/OPERATOR l- PHONE # P7Sq h, C CONTRACTOR NAME PHONE O .,4—/o Z y N CONTRACTOR ADDRESS CA LIC # CLASS T / vv Cil �v�r y37` A r3-c-� Hrfzc-2i R INSURER /�1 C WORK.COMP.# A C OTHER INFORMATION T — 0 PHONE # R PHONE # TANK 10 # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39 —C T 39- A 39- �• N 39- K 39- 39- 39- P 9-39- 39-P L ✓ APPROVED APPROVED WITH CONDITION(S) DISAPPROVED A (SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME z ^ �ti DATE APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: - TITLE �u..f y DATE /3 9 BILLING INFORMATION: Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. Name Mailing Address