COMPLIANCE INFO_1990-2001 - Laserfiche WebLink

Home Browse Search

00 APPLICATION FOR UNDE*VAL ND TANK RETROFIT, TANK LINING, OR PIPING IR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE DATE. DO NOT WRITE IN ANY SHADED AR INDICATE PERMIT TYPE BELOW: TANI' REPAIR/RFTROFTT TAUT iTUTUr_ otetur ocoato I1lillllilfill] 111111111111111 39 - TANK ID T TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED T 39- � I A 39- N 39- 1 K 39- 39- 39- P 1111 j L 7APPROVED APPROVED WITH CDNDItION(S) DISAPPROVED A r SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME �. DATE 111(111111lllill1111tf! 1 11 tlllllll!!flillll!!1! llillllllllllllll111 11 11111tII1!!lllffl! 1(111 Illlillllllll 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: "I CERTIFY THAT IN THE ARFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I LL EMPLOY P RSONS SUBJECT TO WCRKER'S COMPENSATION LAWS OFL FORNIA," , APPLICANT'S SIGNATUR • 4 TIT ° % `` 1 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 bill -n b signature a date, below. Ze2& Name � l nn Mailing Address J a / C! CY Day Phone Numbe. ��r ) Signature �// _/�/� (�, EH 2 3-G038 � 1 EPA SITEI PROJECT CONTACT & TELEPHONE 9 / F FACILITY NAME=/ ' PHONE A / C I ADDRESS L I CROSS STREET 7 YIvKJ OWNER/OPERATOR PHONE 0 �/ 0(.�✓� / 7� CONTRACTOR NAME PH `JC o jj N CONTRACTOR ADDRESS CA lIC X CLASS A I INSURER r /1Q/iii I WORK.COMP.. C I OTHER INFORMATION T 0 I PHONE if R PHONE 4 I1lillllilfill] 111111111111111 39 - TANK ID T TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED T 39- � I A 39- N 39- 1 K 39- 39- 39- P 1111 j L 7APPROVED APPROVED WITH CDNDItION(S) DISAPPROVED A r SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME �. DATE 111(111111lllill1111tf! 1 11 tlllllll!!flillll!!1! llillllllllllllll111 11 11111tII1!!lllffl! 1(111 Illlillllllll 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: "I CERTIFY THAT IN THE ARFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I LL EMPLOY P RSONS SUBJECT TO WCRKER'S COMPENSATION LAWS OFL FORNIA," , APPLICANT'S SIGNATUR • 4 TIT ° % `` 1 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 bill -n b signature a date, below. Ze2& Name � l nn Mailing Address J a / C! CY Day Phone Numbe. ��r ) Signature �// _/�/� (�, EH 2 3-G038 � 1