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nc,.Lin ;IIVISICN <br /> edP <br /> � •„ APPLICATION FOR UNDF Ol1ND TANK RETROFIT, TANK LINING, OR PIPING 4IR PERMIT 17 <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br /> EPA SITE I PROJECT CONTACT & TELEPHONE # <br /> F FACILITY NAME C / ,� <br /> A l� PHONE \ 3 ` l\N�- <br /> C ADDRESS 1 <br /> I \1 \\ L` u +\ <br /> L CROSS STREET v A1C\ <br /> I <br /> T OWNER/OPERATOR PHONE 9 <br /> C CONTRACTOR NAME / PHONE 0 <br /> 0 -C3 l_ <br /> N CONTRACTOR ADDRESS �.l �oG� `lam CA LiC G CLASS <br /> T C1� <br /> AINSURER Ac�C�C�r / WORK.COMP.A�t- quos- <br /> C OTHER INFORMATION <br /> T <br /> R �<� Cz� ` Ilk d \� \� \`(\ PHONE # Lo> �C4,S <br /> PHONE 0 <br /> 111111111111111111111111!11111 <br /> TANK ID TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- l \O er cr <br /> T 39- <br /> A <br /> 9 A 39- <br /> N 39 <br /> K 39- <br /> 39- <br /> 39- <br /> P 11111TfT1T1TTT1Ti <br /> L APPROVED —y— APPROVED WIT CONDITIO ) DISAPPROVED <br /> 5 ATTACHMENT WITH CONDITIONS) / <br /> N PLAN REVIEWERS NAME DATE <br /> lllllllllllllilllllllll111111111111111111111 111111 Ill 11111 TI III 111 I 1 iil�Ti11111 Ilillllll liillllllllilililll <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOACUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S CqMPfNSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "1 CERTIFY THAT IN TPER RMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF ,CALIFO N A." <br /> APPLICANT'S S RE: — ` TITLE �2\r- O\h0Sk6 DATE <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-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 acknowledge this responsibility for <br /> the billing by signature and date (below. n <br /> Name Fc-gco 2,-, ! o <br /> v ii Ing <br /> Mailing Address L lsa'kr ��e�� �r- \ R \K�Wti" cp�,- qcj(. 3 <br />