COMPLIANCE INFO_1986-2002 - Laserfiche WebLink

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ENVIRONMENTAL HEALTH DIVISION .r---® APPLICATION FOR UNDERGROUNWAIRMNK RETROFIT, TANK LINING, OR PIPING REPA RMIT 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 A PIPING REPAIR Y - (LING PROJECT CONTACT & TELEPHONE ILITY NAME d� PHONE C ADDRESS �ry L CROSS STREET T OWNER/OPERATOR Y 'Se` PHONE # N C CONTRACTOR NAME D - PHONE TCONTRACTOR ADORESSg �® �� ® �' CA CLASS R INSUREAiR A WORK.COMP.# C OTHER INFORMATION i 2 PHONE # Illllllltllllltlllltlltlllttll PHONE # TANK !0 # 39 - TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 1 39- A 9- V 39- ( 39- 39- 39- Illl APPROVED APPROVED WITH CONDITION(S) DISAPPROVED (SEE ATTACHMENT WITH CONDITIONS) N REVIEWERS NAME .a1111(IIIIIItl111 DATE II I it 11 I II !lIII III 11 ! IIIIIt 1II1 1 1111111 1 11 1111 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS ')F SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THA:" IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT SUBJECT TO WORKER'S COMPENSATION "I IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME LAWS F CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: CERTIFY THAT IN THE PERFO COMPENSATION LAWS OF CAL FORNI E WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S APPLICANT'S SIGNATURE: _... TITLE z-:�I DATE/— ATE, (LING INFORMATION: icate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the ty designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for billing by signature and date below. , �Y e�7 ting A Phone nature ?3-0038 1 a a C r, a Y