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r600 G ENVIRONMENTAL HEALTH DIVISION � L`E APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING RWR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: TANK REPAIR/RETROFIT TANK LINING PIPING REPAIR III 1111 l I I TANK l l i l l l 11111111 TANK D TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE USI INSTALLED 39- ? I u% / C" 14 0,0 t- 7 T 39-..p / (' K� n yL A 39- 2 / PL N 39- K 39- 39- 39- IIII P L APPROV7//*?CHMENT ED WITH CONDITION(S) _ DISAPPROVED A WITH CONDITIONS) Lam% N PLAN REVIEWERS NAM DATE !! 1111111111111111111! II 11 III iii 111111111 Illitlilll i Illliilllillllll I iii lull Illllli APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: /� L /� ""`1`_ TITLE �� 5 / �� / DATE �7 BILLING INFORMATION: 1/o Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signatureanddate below. Name � t- ,i -",(j 514-6+, .,, r— , ' -- - /' �� � a Mailing Address Day Phone Number Signature EH 23-0038 1 EPA SITE # ! PROJECT CONTACT & TELEPHONE # (.a S 'Z V - (vC S - p qx, F FACILITY NAME �%Lln� PHONE �C %2 - A C ADDRESS J -7 o ., Gl�l C'_ .� . ��C-k-%CA—) L CROSS STREET — I OWNER/OPERATOR PHONE # �,y{ Y C CONTRACTOR NAME (1 1 ,� �' PHONE #�S'_ 7 0 N CONTRACTOR ADDRESS b • C >L i O CA LIC # L f� CLASS / R INSURERL G(` - WORK.COMP.#i; A C OTHER INFORMATION T 0 Ak PHONE #j R PHONE # III 1111 l I I TANK l l i l l l 11111111 TANK D TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE USI INSTALLED 39- ? I u% / C" 14 0,0 t- 7 T 39-..p / (' K� n yL A 39- 2 / PL N 39- K 39- 39- 39- IIII P L APPROV7//*?CHMENT ED WITH CONDITION(S) _ DISAPPROVED A WITH CONDITIONS) Lam% N PLAN REVIEWERS NAM DATE !! 1111111111111111111! II 11 III iii 111111111 Illitlilll i Illliilllillllll I iii lull Illllli APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: /� L /� ""`1`_ TITLE �� 5 / �� / DATE �7 BILLING INFORMATION: 1/o Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signatureanddate below. Name � t- ,i -",(j 514-6+, .,, r— , ' -- - /' �� � a Mailing Address Day Phone Number Signature EH 23-0038 1