COMPLIANCE INFO_2002-2007 - Laserfiche WebLink

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T a N K P A N A S S I CERTIFY T.ti,T IN TWE PERFORMANCE OF THE WORK FOR WHICH THIS PtRMIT IS I5SUED, Z SHALL EMPLOY PERSONS SUBJECT :'O WORYZRIS COMPENSATION LAWS OF CALTFORNXA.,, OG/27/2001 13:57 2094G2&33 FIFTH FLOOR 41 ^P APPLXCATXON FOR UNDERGROUND n RETROFIT, OR PIPING REPAIR PERMIT +/y THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DD NOT WRITE IN'ANY SHADED AXSAS. INDICATE PERMIT TYPE HJUL 2 2 —TANK RETROFIT PIPING REPAIR EPA SITE 1{ &nTEIEPN$ PROtT®'CGGI APPLICANT THE tT3.7ECT �/ c� gC-O�NTACT FACILITY NAME GW957-0,P J 10,P MAP-[ l J / � PHONE tl 2 � ` 9, , ? -4 -73 ADDRESS - 1030 S. ®L- f V E AVE. E. J 1 V t -IC t) (, A. 552 -06 - ✓ 2-®5 f CROSS f CRASS STREET I OWNER/Orm ATOR Q U l KS / V T % I A kX F- (� /N c . tIt pFiONE 1#//�'/']� j� ��r7��. �% �Y'(�® �°7� /�®gyp /j �� . IMC O 1 C51 0) 45'V57 � ?6 �p� �g CONTRACTOR NAME � /AfJ� ENV /ROMAI �%AL 1 ,%A%c . PRONE B I t 8` 4)--70 Z0 � CONTRACTOR ADDRESS ,1 ,757 (A/ r� a I L% A^A14 3W.D . f CA LIC G I CLASS `` tBU�C I 01 �BAKK e eA 915D � ( WORK.COMP. a f OTHER INFORMATION I j f I PRONE T I I PRONE y �I!lllllllflllililllllllllllill� TANK ID # TANK SIZE CHEMICALS STORED CDRR%.WTLY/PREVIOUSLY DATE UST IN5TALLED 39-- 9- 39- 39-39-3 39- 5 39- 119' 1 I 1 I Illllilltllllllllillllllilllt11t111111111tilillii111i1 iiillllttlillll 111 1 Il llill(1[lilllilll t l� ! 1 ill 8� lllll1 T APPRO 1 APP VED WITH COAD ION($) DISAFPROVaO ,. (Sze A A WITH CO IONS) I PLAN P.£VIEWERS NAME DATE it11t111lElltllElllllllll !11!11 t lith ii it l !till f111 i1111llllti11t1i1t111111111111 !I Ili llllllllltltllllil MUST PERFORM ALL WORK IN ACCORDANCE WI—IN SAN JOAQU2N COONM O��X�tnuCES, STATE :AWS, AFa auLES ANa RsGVLATTOn75 of i :.N JOAQUTN COUNTY BiTBLTC HE;J.T1' $yRVIC=$. OWNsR OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING! "I CERTIFY THAT IN I PERFORMANCE OF :`fDi WORK FOR WHICH THIS PERMIT 2S ISSUED, $F:AL.L NOT c.iPLOY ANY PERSON IN SUC:i A MANNER AS i0 BECOME ) TO WORKER'S COM2£N$aTION Law$ OF ClI.SFOZ`1rA." CONTRACTOR'S HZR_VG OR SJ2CONTQACTSNG S2G_.'A=.TRE CERTIFIES T:tE FOLLCW:NG_ I APPLICANT'S SIGNATURE: ./ TITLE �'L.-�®� DATE BILLING INFORMATION; indicate the responsible party to be billed for additional PHS -EM staff tire 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. TRIAA &I-ff e,?�-25 W. Bu R BANK $LVD. Name �h//KLx/MC->,/77ri[. address b(12BA-A[K; L°i} , phone number( - 9') -Z020 Si.gxxature r lti EH 23-0038 � D � 1 ��-_,[1WE[ 40 Lf JUL 2002 ENVIRONMENT HEALTH PERMIT/SERVICES % �"`2-13)