COMPLIANCE INFO_1999-2005 - Laserfiche WebLink

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APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT THt 'P M[T EX,PIRES 90 DAYS FROM THE 0VAL DATE. DO NOT WRITE IN ANY SHADED AR INDICATE PERMIT TYPE BELOW: _TANK REPAIR/RETROFIT TANK LINING OAPIPING REPAIR EPA SITE # PROJECT CONTACT & TELEPHONE # F FACILITY NAME A C ADDRESS /�/ I /� L CROSS STREET I T OWNER/OPERATOR Y til / j/1i JPi -74 C CONTRACTOR NAME 0 '- /AIC— - N CONTRACTOR ADDRESS W CL,8A)#j40j CA LIC # T R INSURER G U A C OTHER INFORMATION T 0 R 39 - III PHONE # PHONE # / 79.2 33Y/ PHONE2C)9— C) _ 6&8 _ g 43 (P -? / W CLASS 64,1 WORK.COMP.#IVWL r 39000 PHONE # PHONE # TANK SIZE CHEMICALS STORED CURReNTLY/PREVIOUSLY I DATE UST INSTALLED P.......................................................................................same L APPROVED _ APPROVED WITH CONDITION(S) _ DISAPPROVED A (SEE ATTACHMENT WITH CONDITIONS) MilliPLAN REVIEWERS NAME DATE III(II11111(Illtl((I IIIII I 1111 II III IIII 1 !I (! 11 III I 1 1 I!lIII III 11111111111111111 !1111 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 CALIFORf{iA." APPLICANT'S SIGNATURE: BILLING INFORMATION: TITLE DATES—�/ Indicate the responsible party to be bitted for additional PHS -END 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 bit t g by signatu date below. s Name Mai l in Address /) /7,Z tllltl1111t11111t1111tt111111I TANK 10 # 39- 3 39- A 39- N 39- K 39- 39- 39 - III PHONE # PHONE # / 79.2 33Y/ PHONE2C)9— C) _ 6&8 _ g 43 (P -? / W CLASS 64,1 WORK.COMP.#IVWL r 39000 PHONE # PHONE # TANK SIZE CHEMICALS STORED CURReNTLY/PREVIOUSLY I DATE UST INSTALLED P.......................................................................................same L APPROVED _ APPROVED WITH CONDITION(S) _ DISAPPROVED A (SEE ATTACHMENT WITH CONDITIONS) MilliPLAN REVIEWERS NAME DATE III(II11111(Illtl((I IIIII I 1111 II III IIII 1 !I (! 11 III I 1 1 I!lIII III 11111111111111111 !1111 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 CALIFORf{iA." APPLICANT'S SIGNATURE: BILLING INFORMATION: TITLE DATES—�/ Indicate the responsible party to be bitted for additional PHS -END 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 bit t g by signatu date below. s Name Mai l in Address /) /7,Z