Laserfiche WebLink
•-s <br />F <br />A <br />C <br />I <br />L <br />I <br />T <br />T <br />C <br />0 <br />N <br />T <br />R <br />A <br />C <br />T <br />0 <br />R <br />2-19-1998 10 - 34AM FROM • P.3 <br />f ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />TANK REPAIR/RETROFIT TANK LINING , PIPING REPAIR .,•- T4 n k mDn,��� Pwb <br />EPA SITE # PROJECT CONTACT $ TELEPHONE iF 71'C4GK 9, hoc, Atts S3 S <br />FACILITY NAME t lCil.U ( C -cin -1 ctn C1�o�' jf PHONE 2 DZ)Cj— y(eD- 3 (� <br />ADDRESS -33q+j �� CA�• e.s w lo1z C�C� S `►-O Ck to n . ea <br />CROSS STREET P C 4. A V-e- <br />OWNER/OPERATOR wl C'k O ,+ 1 CCD rn P C{ (I <br />CONTRACTOR NAME E I 1 f e- I V Cvn-} rc, <br />CONTRACTOR ADDRESS c;)S 3 S <br />INSURER g �ny 1 'C D 1`1 Yft N, r1+. Q <br />OTHER INFORMATION <br />5 T- R C- <br />PHONE 9 <br />530 -?53S— 096 1 <br />PHONE 0 ;209-L4te I - (033 1 <br />CA LIC 11 RtiA?-ld(,c-j CLASS A <br />2 i 1 I I WORK. COMP -9 <br />r Ufa 11) A <br />PHONE 9 <br />I1111111111111111111111111f111 PHONE it <br />TANK IO # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- Wa'IU t IC),0 >r-> Pvtyuiar unl�ua{tcl Gc i,.J.r.t <br />T 39- -a"7 .1 10 1 Ddb m�riMv.0 unlsri�d C� IIrt Ci3 <br />A 39- 00 <br />N 39- <br />K 39- <br />39- <br />39- <br />111111111 fill IIIIIIIII 111111 <br />P <br />L APPROVED APPROVED WITH CONOITIONCS) _ DISAPPROVED <br />AE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE r"' K <br />1111111111111111111! Illfl <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERFORMANCE OF THE WOFOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." , /I 9 <br />APPLICANT'S SIGNATURE: '' /hTITLE I)t r. ul L11QQ) u ( [ y- � DATE <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. if the <br />party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br />the billing by signature and date below. <br />Name 1. 4 Iy l fl <br />Mailing Address_ <br />Day Phone Number C <br />Signature <br />EH 23-0038 ��' � L t ' zz <br />