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ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERIR40K RETROFIT, TANK LINING, OR PIPING REP MIT <br />t <br />I <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 />� BILLING INFORMATION: <br />Indicate the responsible <br />EPA SITE #CA C o © <br />PROJECT CONTACT & TELEPHONE it <br />F <br />A <br />FACILITY NAME � • -�. 'b -PHONE <br />Z\.,�� <br />applicant, e.g. <br /># <br />C <br />ADDRESS <br />I <br />Name C- <br />0 —X\ <br />L <br />I <br />CROSS STREET <br />kx <br />Mailing Address <br />T <br />Y <br />OWNER/OPERATOR <br />l Q`cac�.l�rc <br />PHONE # <br />�ZC <br />L o (— <br />C <br />CONTRACTOR NAME <br />PHONE # <br />0 <br />N <br />CONTRACTOR ADDRESS \-)"Q\ `, K)c <br />CA LIC #Qk"� <br />CLASS <br />T <br />A en <br />R <br />INSURERm��tSfJ �1 1r�r <br />WORK.COMP.# �X <br />C <br />OTHER INFORMATION <br />T <br />0 <br />PHONE # <br />R <br />_ <br />illllilliillliillllililillllll <br />TANK 1p # TANK SIZE <br />PHONE # <br />CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE'UST INSTALLED <br />39- <br />,CkS\01-311i. <br />T <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P <br />! 111 <br />L <br />I APPROVED _ APPROVED WITH <br />CONDITION(S) DISAPPROVED <br />A(�� <br />(' E ATTACHMENT <br />WITH CONDITIONS) <br />N <br />PLAN REVIEWERS NAME k]w <br />lliiltlll!!ilI11!lllllll sill! I lif if I I I 11TI-11711111111 IIIII <br />DATE <br />I llllll 11111 I IIII1111lII11 ilil I11111111lIIlIltilillli <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN <br />COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED <br />AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I <br />SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMP ENSATLAWS OF CALIFORNIA." CONTRACTOR'S <br />HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"1 <br />CERTIFY THAT IN THE PERF MAN OF THE WORK FOR WHICH THIS <br />PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S <br />SIGNATURE: <br />TITLE t N' e "1VE DATE Z S <br />� BILLING INFORMATION: <br />Indicate the responsible <br />party to be bilLed for additional PHS-EHD <br />staff time expended beyond permit payment coverage per tank. If the <br />party designated below is <br />different than the permit <br />applicant, e.g. <br />property owner, the party must acknowledge this responsibility for <br />the billing by signature <br />and date below. <br />Name C- <br />0 —X\ <br />Mailing Address <br />*\'C <br />Day Phone Number <br />� Signature <br />EH 23-0038 <br />3J <br />