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5-26-1998 1:d8PM FROM <br />s Y ENVIRONMENTAL WEALTH DIVISION <br />• ¢• APPLICATION FOR UNDERGZCUNA TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL ��DATE. <br />�/ �DDO HOT WRITE IN ANTS . INDICATE PERMIT TYPE BELOW: <br />�T K EPAAIRR//RE7ROF11 ___TARK LIVING _ PIPING REPAIR <br />W <br />EPA SITE Y w PROJECT CONTACT t TELEPUM 0 7 <br />F FACILITY NAME C K - U� <br />A <br />C ADDRESS 5 <br />I_ <br />L CROSS STREET <br />d <br />T OWNER/GPERATOR PHONE 9 <br />T "� L L.0 . 5/0 33 -SW <br />C CONTRACTOR NAME _ , -` 9 <br />D <br />N CONTRACTOR ADDRESS CA LIC V A MASS �( <br />T A <br />a INSURER Yl WORK.=W.N <br />A <br />C OTHER INFORMATION <br />T <br />OPHONE S <br />PRONER <br />1I11111111TANK IlolxllllllIIIII TANK SIZE CHEMICALS STORED LY/PREVIOUSLT DATE UST INSTALLED <br />T 34- <br />A 39- <br />N 39- _ <br />K 39- <br />39- <br />39- <br />P <br />9 -39- <br />39- <br />P <br />L APPROVED APPROVED WITH CONDITTONCSB ® DISAPPROVED <br />A ATTACHMENT WITH CONDITIONS} <br />N PLAN REYIfWERS NAME OATS (1 <br />1ill1111111111fill 1I 1 I i ! ii ii !lilt ! !!Illi <br />APP.ICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN CMIRTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY MAU C WEALTN SERVICES. OWNER OR LICOM AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANC! OF THE WORK FOR WHICH THIS PERMIT IS ISM, d SMU HOT EMPLOY ANY PERSON IN S= A MANNER AS TO BECOME <br />SUNWECT TO 'S COMPENSATION LAWS OF CALIFORNIA." CUNTRACTORIS MIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERFCRXAMCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, t SNALL EMPLOT PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS Of CALIFORNIA." J <br />APPLICANT'S SIGNATURE: L /� , TITLE .=, ! CR 7� DATE ?� <br />BILLING INFORMATION* <br />Indicate the responsibte party to be bitted for additional PHS-EHD staff time expended boyald permit payment coverage per tank. If the <br />parr/ designated beton is different than the permit appLicait, e.g. property owner, the party must acltnoutedge this respm+sibility for <br />the bitting by signature and date betoW. <br />Mai(in} Address <br />Uv <br />Day phone NuMber <br />Signature <br />;H 23-0038 <br />9 <br />