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07/15/98 15:26 N0.276 EP02 <br /> ' +•MVtr<NnhttltAl 11tAltfl w1V1SION <br /> APPLICATION FOR UNDERGROLL RETROFIT, TANK LINING, OR PIPING REPAIR P* <br /> S 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 N J PROJECT CONTACT i TELEPHONE f <br /> F FACILITY NAMEWoPHONE 0 <br /> A <br /> C' ADDRESS <br /> L CROSS STREET <br /> I PHONE B <br /> 7 OVNER/OPERATGR j I 11 - 55 '} . <br /> C CONTRACTOR NAME PHONE ! 395.11 2- <br /> 0 <br /> N CONTRACTOR ADDRESS CA LIC I d CLASS <br /> T YORK.00?(-1 O - <br /> R INSURER 6wrxg <br /> A <br /> C OTHER INFORMATION <br /> T £ <br /> 0 <br /> R PHONE A , <br /> I <br /> ttttttttlttANXj tot tittltttitt TANK SIZE CHEMICALSINTLY/PREVICUitY DATE UST INSTALLED <br /> 39- i9998"_ <br /> f 39- ,•�P <br /> A 39- <br /> N <br /> K 39- �� <br /> 39- <br /> 39- <br /> P <br /> tltt <br /> L APPR _ APPROVED WIT CONOITION(S) DISAPPROVED <br /> A '(SE£ NT B CONOiTIONS) <br /> R PLAN REVIEWERS NAME DATE <br /> III 1111111111ttlfill ttttt <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH COUNTY ORDINANCES, STATE LAYS, AND RULES ANO REGULATIONS Of <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES- OWNER OR t N T'S SIGHATURE CERTIFIES THE FOLLOWING. "I CERTIFY THAT IN <br /> TME PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT 13 SUW, 1 !HALL NOT E1IPLOY ANY PERSON IN SUCK A MANNER AS TO WOKE <br /> SUBJECT TO WORKER'S COMPENSATION LAWS Of CALIFORNIA." TRACTOR'S HIRING ON SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOW194; <br /> "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 13 ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIF IIA. tAlt,02 AV I/^ <br /> APPLICANT'S SIGNATURE-. TITLE DATE <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-END staff time expended beyond permit payWt Coverage per tank. If the <br /> party designated below Is different than tiea permit appticant, e.g. property owner, the party must acknowledge this per <br /> for <br /> the billing by signature and dacebotow. ' <br /> Rome +^'{ AA WS ;' <br /> ai i Ing Address o' r. OG�2 -�06b <br /> Z• Ac1b ^0 c'y<-j z d vim- <br /> s <br />