Laserfiche WebLink
ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR -0ERGROUND TANK RETROFIT, OR PIPING REPAIR PE. ..T <br /> THIS PERMIT [XPIRES 90 DAYS FROM <br /> THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> ✓_TANK RETROFIT PIPING REPAIR* <br /> EPA SITE 1 PROSECT CONTACT 6 TELEPHONE 1 <br /> FACILITY NAME PHONE <br /> Q l C 'fGul_ l J <br /> ADDRESS 'r' 'L5 <br /> % <br /> _'ROSS STREET <br /> OWNER/OPERATO� lr t.��F PHONE I u r <br /> CST✓� �rs'� X <br /> ONTRACTOR NAM 1 CI. L"CZIN V 2Vk(� �t�IQV Ezgp --�yC.: PHONE 1 <br /> CONTRACTOR ADORES �� p,•tom _ I CA LIC tl •`/1� wl FC <br /> 'NSt-'R E2 - / l' I WORK.COMP.R ��(!J'( �j •� <br /> =-IER INFORMATION <br /> i <br /> PHONE 9 <br /> PHONE I <br /> 111111111111111111111111111111 <br /> TANK ID I TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED I <br /> 79- f I I <br /> 1 79. I I <br /> .•r I <br /> )9- t -- <br /> 79- <br /> I9. <br /> I Ili I � Tfii i iTTiiiTTftTiil-iTiTi i i <br /> APPRROVED7ATTACHMEXT <br /> PPROVED WITH CONDITIONS) DISAPPROVED <br /> j WITH CONDITIONS) 3�V��� <br /> REVIEWERS NAME DATE J <br /> -�IIIIIIIillllllllllli r 111111 I illlllllll <br /> PLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN ,;OAQVIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH S RVICES. OWNER OR 'LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN <br /> ?E PEP.FOR.'1ANC£ OF THE WORK FO R WH CH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> 5'-WELT TO WORKER'S COMPBN ATION WS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLCWIN,; <br /> CERTIFY THAT IN THE PERb ) R1t-f6R,�lHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> "OMPENSATION LAWS OF IF IA.' ! <br /> A?PLICA.'rT'S SIGNATURE: TITLEtA�pW 1�/ r �jpTgS <br /> _:LLING INFORMATION: <br /> 'ndicate the responsible party to be billed for additional PHS-EHD staff time expended be%-D.- <br /> permit payment coverage per tank. If the party designated below is different than the perm, <br /> applicant, e.g. property owner, the party must acknowledge this responsibility for the bili: <br /> by signature and date below. <br /> Nan y`P � �uZ�address l y3LCL r/ y)A- -- phone number <br /> Z3Yk <br /> S•_grature � �y <br /> 23-0038 <br /> 1 <br />