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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDE TANK RETROFIT, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMI" TYPE BELOW: <br /> lj(Q/ _TANK RETROFIT )( PIPING REPAIR <br /> v_ 7-PA <br /> S:To /+ A,1_ 0 O 0 31 y v, PROJECT CONTACT 1, TELEPHONE # AA iIz� V_A,(t v�L 0 t- SIO - y'Jr Z 2s S1 <br /> F FAC:LITY NAME Q,)jj( S-rop 1MAr/L lL&A- tV- 13 Z' PHC1-z # Z Oct _ cJ s- <br /> r ADDRESS rT-� uj- Ia AVhyyI FiYL. L A� r S ro CIL T O nd <br /> • r <br /> _ -ROSS STREET 'A,, 1 µ�K S �y\� Vr <br /> s ^ OWNER,OPERATOR YI` �I PHC\: U <br /> T3A,L B c>_ T4SwA6"A�6 , b41LLoN - rtIen.( Cu1SkCs ! zOq - cj rl - 3I9_ l - <br /> CONTRACTOR NAME AL GrA EAI(, a.464 rtrhl(, � C PHC\_ # <br /> W <br /> 0 r Wr G <br /> N I CON^RACTOR ADDRESS Pao. Bay 102 <br /> I CA LIC # [ 1 3 I CLASS /� <br /> W S4GrtAw.f,.uro CA 9S_6ti1 v A , µ <br /> R :NSURER S T Arl-r, r-7t/M,)1:,, I WOZ!.COMP.# I13 - 44ct Z } -O O <br /> A <br /> 0:riER :NFORMATION CC)a rA C.T + Y(/(( CAA ArS L WA' L(GN <br /> PHC.vza q�b - 3 �3 - IIrZ <br /> PHC\L # <br /> —IIIIIIIIIIIIIIIIIIIIIIilllllllll <br /> TANK ID # TANK SIZE CHEMICALS STORED CURREN—_-!/PREVIOUS"'! DATE USf INSTALLED <br /> 39- ( 1 /O, 00 O C A. 0W I u*lL G ASOLrngE - rcF_ <br /> T I 39- 0 ia0 O •� I uAt, <br /> A I 39• AT_31 IC!! 000 •• I .�K� •` PnE� - q 2. I �5 t <br /> N I 39- 1 <br /> K139- I I <br /> 39-39- <br /> I I I <br /> --111111111111111111111111111111111111 IIIIIIIIIII III Illilllllllll IIIIIIIIIIIIIIIIIIIIIl11111111111111111111111111111111111I <br /> L I AP R VE PROVED WITH CONDITION(S) DISA??ROVED <br /> A I ATTACHMENT WITH CONDITIONS) ` <br /> N I PLAN REVIEWERS NAME v DATE <br /> —IIIIIIIIIIIIIIIIIIIIIIIIIII 1 1111 1 I 11 1111 lllllllllilllllillilllllmni IIII 1111111III1 1111 It <br /> APP'-:CAN- 'OUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES = FOLLOWING: "I CERTIFY THAT :N <br /> -HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON :N SUCH A Y.A.NNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES CERTIFIES THE FOLLOWING: <br /> CER-:FY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS .SUBJECT TO WORKER'S <br /> =OMPENSAT:ON :.AWS OF CALIFORNIA." <br /> APP'-:CANT'S S:GNATURE; 4TITLE f%6-C It Ijt-+� DATE 1 rZ 0 1 <br /> W i C i4 A B.L , 1~ IAIA L.T Ont IA/A t-(-0 nl �.c(.r•! /`si n a K� "�+L c <br /> 1 BILLING INFORMATION: <br /> indicate the respenmible party to be billed for addi4iorAj PF38-EHo oc4ff time expanded beyond <br /> permit payment oo'verage per tank. If the party designated bolow in dtfferant than the permit <br /> applicant, e.g. property owner, the party mvct acknowledge thin responsibility for the billing <br /> by siignntureand darn below, <br /> Name/_�� 1C//9"C✓: `f'1* address yS�7 Li✓{s;-2f�"'i e phone number x'16-y Y S-Z <br /> Signature . (< A7 /4'/)-4100�t� <br /> EH 23-0036 <br /> 1 <br />