Laserfiche WebLink
i APPLICATION FOR UNDEK JND :ANK RETROFIT, OR PIPING REPAIR PERMIT <br /> ='HIS PERMIT -EXPIRES 90 DAYS £RCM THE APPROVA. DATE. DO NOT 'WRITE I1: ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _TANK RE'i'=OFIT PIPING REPAIR <br /> EPA SITE # PR CT CONTACT TELEPHCNE # <br /> c I FACILITY NAME OPHONE # D / / 93 <br /> -q/(f c <br /> C 1 <br /> C I ADDRESS { <br /> I <br /> L { CROSS STREET <br /> I � <br /> T I <br /> OWNER/OPERATOR, PHONE/ '# `^_ �J <br /> Y { _ /VY"I /min lVi/.j <br /> C j CONTRACTOR NAME LL - I PHONE # / / (V <br /> { <br /> 0 / <br /> N I CONTRACTOR ADDRESN36 I - I CA LIC # I CLASS <br /> T v� <br /> RI INSURER I WORK.COMP.# <br /> A <br /> C { OTHER INFORMATION { { <br /> T <br /> 0 I { PHONE 4 { <br /> R <br /> iI PHONE # <br /> --�IIIlI11111111I111I1I11111fI1111� - <br /> TANK ZD # TAN". SIZE CHEMICALS STORED CURRENTLY/PREVIOUSL'L DATE UST INSTALLED � <br /> 1 39- <br /> T 1 39- <br /> A 1 39- <br /> N 1 39- <br /> X 1 39- <br /> 1 39- 1 i I <br /> 1 39- I I I { <br /> --11111111111111111111111111111111111111111111111111111111111111111111111111111111111111IIIIIIIIiIIl11111111111111111111111111111 <br /> P <br /> APPROVED _ APPROVED WITH CONDITION(S1v DISAPPROVED 1 <br /> A 1 (SEE ATTACHMENT WITH CONDITIONS) I <br /> :I 1 PLAY REVIEWERS :LAME o..o, DATE \C) <br /> —If tlitlllllltilllllllilil 1111 I II =11TIE1 <br /> lllAPPLICANT MUST PERFORM ALL WORK IN ACCORD �' SAN JOAQUIN COUNTY ORDINANCESLAWS, AND RULES AND REGULATIONS OF j <br /> SAN JOAQUIN COUNTY PUBLIC HEAL--I SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THA'Y IN j <br /> -1- <br /> .%- 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 COMPENSAT 0- LAWS OF CAL:: - CONTRACTOR'S HIRING OR S RACTING SIGNATURE CERTIFIES THE FOLLOWING:) <br /> "I CERTIFY THA: IN THE PER '`7 OF THE WOR.: FOR WHICH THIS PERMIT IS ISSUED, S L EMPLOY PERSONS SUBJECT TO WORKER'S I <br /> COMPENSATION LAWS OF CALIFO I,,/- <br /> APPLICANT'S <br /> A -:,2PLICANT'S SIGNATURE: TZ •GI.cDA <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-EHD 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 uL'7aaSddress u - phone number <br /> Signature <br /> EH 23-0038 <br /> 2,ColE X41 <br /> 1 . <br />