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94474T UL, 13:57 2094683 FIFTH FLOOR PAGE 02 <br /> AFPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br /> :HIS FERMYT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO D)OT WRITE IN ANY SHADED A85aS_ INDICATE PERMIT TYPE BELOWs <br /> ��TANK �TAOFZT jL//PIPING REPAIR <br /> EPA SITS 9 PROJECT CONTACT & TELEPHONE 9 <br /> p FACILITY NAME Q(�/KS/ OP /�JAkKETS ��� PHONE q <br /> A of 7 ✓ 7 <br /> C I ADDRESS 3555 W #AHIVEQ LAVIF 7DA-1 I <br /> I <br /> L I CROSS STREET <br /> I <br /> T OWNER/OPERATOR //'/4C—TS , We- j PHONE <br /> C I CONTRACTOR NAME %/Q r/(�L E E/SN/,e o41A 5,1 Z- ic/L' PHONE a 8/Ir <br /> 0 <br /> N CONTRACTOR ADDRESS < CIC a CLASSL <br /> T <br /> R j INSURER ( wORK.COMF.S I <br /> A <br /> C OTHER INFORMATION I I <br /> T ' f <br /> 0 I PHONE 3. <br /> I I PHONE x <br /> TANK <br /> -�I1f11[ililIlillllllll!{ll� <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED � <br /> 1 39- <br /> I i I <br /> T I 39- <br /> A i 39- 1 I I <br /> N 1 39- <br /> K 1 39- I I <br /> 1 19-aq- <br /> I I I <br /> --�llllllilllllllllililllllillllllt ililllllllf1111111Ullllilllillll 11 1 1 llilllllll! !I 1 ! t i f I f 1 11 <br /> L I APPROVED APPROVED WITH CONDITIONS) OISAPPROVBD <br /> A [ ($Ze ATTAC:iM£NT WITH CONDI'T'IONS) <br /> N I PLAN REVIEWERS NAME It lA- DAT£ �/�weo I L <br /> -ill[IIM III[III III III1111111111111-111111111 III-f fil 111111111 Mill RIII Ill IIIII mil II1111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY 02J3YNANCES, STATE LAWS, ANn RULES AND REGULATIONS OF i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SSRVICSS. OWNBR OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING! "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PRRMIT IS ISSUED, I SuA:.i. NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME I <br /> SUBJECT TO WOAKER•S C40M2ENSATXON taws OF C?.LIFQWZA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOW:NG:I <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUM, I SHALL EMPLOY PERSONS S-aJECT TO WORKER'S ) <br /> COMPENSATION LAWS Of CALIFORNXA." <br /> APPLICANT'S SIGNATURE: , •�' ' NVQ-� TITLE u�+'/Iwi"G%� DATE v _ <br /> f <br /> BILLING INFORMATION: <br /> indicate the responsible party to be billed for additional PHS-EBD staff time expended beyond <br /> permit payment coverage per tank. If the party designated below is different than the permit <br /> applicant, e.g. property owner, the party must acknowledge this responsibility for the billing <br /> by signature and date below. <br /> Name address phone number <br /> Signature <br /> EH 23-0038 <br /> l - <br />