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2004 16: 30 209 433 FIFTH FLOOR PAGE O1 <br />;.»+• VVIRONNSYTAL HEALTH DIVISION <br />APPLICATION FOR VNPBRGROVNP TANK RETROFIT. OR PIPING REPAIR PERMIT <br />THIS PERXIT EXPIRES 90 DAYS FROM M APPROVAL OATS. WRITS IN ANY SHADED AREAS. INDICATE PERMIT TYPO BELOW: <br />_TANK; RETAOFTT � PING REPAIR 'g p'!^ I <br />• SPA SITE ® PROJECT CONTACT 6 TELePHOPM SA/',,,_ /-7 _per„ ,�.` ����, I•y7?-,�. <br />r I FACILITY HANE T"C,,. C'�sc^'�� Ak— AJ,In PHONE 9 <br />A i _'Y _�...�R! zo9 <br />C I ODOR CSS An <br />CROSS 9T4ErT <br />I <br />! OWNS CPE To PHO�NB�pS <br />C j CONTRACTOR NAME2 PHONE g O <br />N CONTRACTOR <br />P IN-SURE ADDALS1 CA LfC pJ to �Aly6 <br />O <br />(� L -K --14,4N D4�� WORK COMP. 6Z, <br />C I OTHER INFORMATION <br />T <br />PHONE P <br />A � <br />, <br />PHONE S <br />TANK ID 1 TANK SIZE CHEMICALS STORED CURXS`NTLY/PREVTOUSLY DATE UST INSTALLED <br />)9• <br />A 31- <br />K )9• <br />P IIS' !IMT1i1IffM 1iTTTTi <br />ROV90 APPROVEP WITH CONOITLON(S) DISAPPROVED <br />LAM <br />A SEB ATTACHMENT WITH CONDITIONS) <br />v PLAN REVIEWERS NAME OATS <br />PLICaNT RUST PERFORM ALL MORE IN ACCORDANCE WITH SAN :OAQVIN COUNTY ORDINANCES, STATE LAMS, AND RULES AND ReCVLATION- OF <br />SAN JOAQUIN COUNTY PUBLIC HEALT'R SERVICES. OWNER OR 'LICENSED AGENT'S SIGNATURE CBRTIPIBS TNS 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 MAMMA AS TO BECOME <br />SUB:ECT TC WORUR'S COMPENSATION L.Rs OFCALIFORNIA,'• CONTRACrOR'S BIRINO OR RMCONTRACTTNC SIGNATURE CERTIFIES TATE FCLGO•+1'+G <br />I CERTIFY THAT IN THE PO MORA POR WHICN THIS PERMIT IS ISSUED, I SRALL EMPLOY PCRSONS SU9JECT TO YORKER'S <br />:aMPQ9SATION LAWS OF IP A.• <br />APFLICANr'S SIGNATURC: TITLE�9 DATE I ;J OHO <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional PHS-EHD staff time expended <br />permit payment coverage per tank. If the party designated below is differenc than the Dear: <br />applicant, e.g. property owner, the party must acknowledge this responsibility for the bi'_lir. <br />by signature and date below. <br />Name addr ss phone numberZoC6r�{$3_ <br />S icna tur <br />=H 23-0038 <br />1 <br />