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5-26-1998 1 :d8PM FROp 2 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPI2ES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS- INDICATE PERMIT TYPE BELOW: <br /> —ULTANX REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br /> I EPA SITE Y w PROJECT CONTACT L TELEP9M9 e — <br /> I A FACILITY HANE L �— <br /> C ADDRESS <br /> L CROSS STREET Ir <br /> T OWTtER/OPERATOR r PHONE ! <br /> C ! CONTRACTOR NAME _ r S PHONE <br /> 0 <br /> N CONTRACTOR ADDRESS — I CA LIC ! 4^SS �ACLASS �o� <br /> T <br /> AINSURER _ WORK.COMP.'1 <br /> COTHER INFORMATION <br /> T <br /> D PHONE M <br /> R <br /> PHONE R <br /> ' 1i111fi111illl,iilfiilillli111 <br /> TANK 10 x TANK SIZE CNEMICALS STORED CURRENTLT/PREVIOUSLT DATE UST INSTALLED <br /> 59- <br /> T 39- <br /> A <br /> 9 A 39- <br /> N 39- <br /> 39- <br /> 39- <br /> 39- <br /> fill <br /> 9 39- <br /> 39- <br /> 39- <br /> fill <br /> D <br /> L APPRCM _ APPROM W I TTY CM I T TON(S) _ D I SAPPROVED <br /> (SEE.ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME / /l�v�� - L,�--✓�, DATE L <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY QRDINANCES, STATE LAYS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, OWNER OR LICIINSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I C.RTIFY THAT IN <br /> THE P`RFORMANCZ OF THE WORK FOR WHICH THIS PERMIT I5 ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIE5 THE FOLLOWING: <br /> "I CE;TIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERFsIT IS ISSUES, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> I COMPENSATION :AIDS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: 1 /\\ TITLE DATE / <br /> SILLIN6 INFORMATION: <br /> Indicate the responsibte party to be bitted for additional DRS-EHD 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 ackn+owtedge this responsibitiry for <br /> the biLLing by signature and date below. \y <br /> Mailing Address <br /> pay Phone Nuillber ( ) <br /> Signature <br /> (� d r. ��- CIS <br /> Z.4 Z3-0038 L - 1 �' -6�vt VZ-4— 't�e_lJ�t�.cA.- S�n..�-fJ ) <br /> ' v�/1v�1 <br />