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I F ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGff TANK RETROFIT, TANK LINING, OR PIPING REPAaw PERMIT Y 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 ,..e.. PIPING REPAIR EPA SITE # PROJECT CONTACT & TELEPHONE 0 o y C vves ® g F FACILITY NAME® PNONE # p 9 ►� A a o .0 ADDRESS 2 t 072 1 L CROSS STREET T OWNER/OPERATOR ` PHONE # T 00j a asey a �' od C CONTRACTOR NAME /„� PHONE # ® �] 0 .. /L N CONTRACTOR ADDRESS 0s CA LIC # CLASS T R INSURER " K• •# A C OTHER INFORMATION T 0 PHONE 0 R IIIIIIIIII'ANK ID 011111111111 TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- T 39- A 39- N 39- K 39. 39- 39 III I P L APPROVED _ APPROVED WITH CONDITIONCS) . DISAPPROVED AATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME (SEEDATE 11111111111111111111 I I I I I I 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 15 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: "1 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." XAPPLICANT'S SIGNATURE: TdTLE DATE BILLING INFORMATION: Indicate the responsible party to be bitted for additional PNS -END stat# 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 signature and date below. 4 -- M -r= _ / EH 23.0038