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ENVIRUNMENIAL HEALTH DIVISION <br /> t• # APPLICATION FOR UNDEND TANK RETROFIT, TANK LINING, OR PIPING I* PERMIT <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 PROJECT CONTACT & TELEPHONE # t/"I <br /> F FACILITY NAME Zi 33 PHONE # �, <br /> A AROD <br /> 79 <br /> C ADDRESS o enp <br /> 1 0 w <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATORof �� PNONE # <br /> Y /1YI �) rn —S -Q- <br /> C <br /> -C CONTRACTOR NAME !ko spo 4 PHONE # 0 -Zw <br /> 0 ' <br /> N CONTRACTOR ADDRESS 11 1-7 goo 11 ffle CA LIC # (f�0 CLASS 6e,7 <br /> T !/ <br /> R INSURER 1+�✓ WORK.COMP.# 64 Tp <br /> A <br /> C OTHER INFORMATION <br /> T <br /> 0 PHONE # <br /> R <br /> PHONE # <br /> IIIIIIillllilllllllillllllllll <br /> TAN �D # TANK SIZE CHEMICALS STORED RRENT4Y/PREVIOUSLY DATE UST INSTALLED <br /> 39- 1,(y a v-O K^,(��-.c <br /> T 39- Lyo-cly <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> L ILII APLVED APPROVEDWITH CONDITION(S) DISAPPROVED <br /> A / (S ACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME V DATE <br /> 11111111111111111111 I I I I I II II III 1 I 111111 1111111 illIIIIII It illllil <br /> APPLICANT MUST 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 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 COMPENSATION LAWS 0 CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PE MANCE OF H WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CAL OR lA. <br /> APPLICANT'S SIGNATURE: TITLE �Iyj�/� DATE L <br /> -� <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-END 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. <br /> Name c / }}1� <br /> Mailing Address- i� O ao'a� tJ(V{,p <br /> C/ Nk <br /> J <br />