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ENVIRONMENTAL HEALTH bIVISION <br />LAO ZV� <br />APPLICATION FOR UNDERGR TANK RETROFIT, TANK LINING, OR PIPING REPOPERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AR S. INDICATE PERMIT TYPE BELOW: <br />_TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br />BILLING INFORMATION: <br />ndicate the responsible party to be billed for additional PNS-EHD staff time expended beyond permit payment coverage per tank. If the <br />arty designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br />he billing by signature and date below. <br />ame t3 C I t ( r <br />hailing <br />Phan <br />pignatur <br />r <br />r <br />r <br />23-0038 1 ��2un� C -s 1 <br />r <br />PA SITE # <br />PROJECT CONTACT & TELEPHONE <br />a <br />AFI <br />LITY NAME <br />PHONE # <br />C <br />ADDRESS <br />I <br />L <br />I <br />CROSS STREET <br />T <br />OWNER/OPERATOR <br />PHONE # <br />Y <br />C <br />CONTRACTOR NAME <br />PHONE # <br />0 <br />c <br />N <br />T <br />CONTRACTOR AODRM <br />'NIVAt <br />CA LIC # CLASS <br />Lt— <br />R <br />A <br />INSURER <br />WORK.COMP.# <br />C <br />OTHER INFORMATION <br />T <br />0 <br />PHONE # <br />R <br />I lllillllllllllllltltll(tlltl! <br />TANK ID # <br />PHONE # <br />TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39 - <br />T <br />39- <br />A <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P <br />l111 <br />L <br />APPROVED <br />APPROVED WITH CONDITION(S) DISAPPROVED <br />e <br />A <br />( ATTACHMENT WITH CONDITIONS) <br />!' <br />REVIEWERS NAME <br />I1111I1111111111 1 <br />DATE <br />I II ! II 11 II 11 11 ! 111111 1111 1 1! III tl ILII <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE <br />WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. <br />OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS <br />PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS 9F CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERFO <br />WORK FOR WHICH THIS PERMIT 1S ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CAL FORNd " <br />APPLICANT'S SIGNATURE: <br />TITLE ` DATE <br />BILLING INFORMATION: <br />ndicate the responsible party to be billed for additional PNS-EHD staff time expended beyond permit payment coverage per tank. If the <br />arty designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br />he billing by signature and date below. <br />ame t3 C I t ( r <br />hailing <br />Phan <br />pignatur <br />r <br />r <br />r <br />23-0038 1 ��2un� C -s 1 <br />r <br />