COMPLIANCE INFO_1998-2004 - Laserfiche WebLink

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X APPLICATION FOR UN1DE:,ZjLWHD TANK RETROFIT, TANK LINING, OR PIPING IR PERMIT THIS PERMIT EXPIRES 90 DAYS fRC.M THE OVAL DATE. DO NOT WRITE IN ANY SHADED AREA . INDICATE PERMIT TYPE BELOW: TANK REPAIR/RETROFIT _TANK LINING-/`MPING REPAIR BILLING INFORMATION: Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the party desi ed below is different than the permit applicant, e.g. property owner, the party must acknowledge -his responsibility for the bilCi g yi� ture and at low. Name Mailing Address Day Phone Numbg! ) Signature EH Z3-0038 ob, 'r C&-,tt- 0,V py4024-1 I EPA SITE i i PROJECT CONTACT & TELEPHONEG- F ACR FACILITY NAME ( PHONE ;9 ADDRESS eC L I CROSS STREET T Y,! OWNER/OPERATOR _ > PHONE 1 CO 11 CONTRACTOR NAME �% PHONES 1 •� /_ �. l /CLASS i N T CONTRACTOR ADORES li CA LIC /'}` /_ 1 5e R INSURER } . WORK.COMP.w A _ C I OTHER INFORMATION T 0 PHONE 9 R 111i1!lIII1llllll111illllllll! TANK ID r PHONE # TANK SIZE I CHEMICALS STORED CURRENTLY/P EV(CUSLY DATE UST INSTALLED 39- T 39- `w- A 39 W 'Q�AI � N 39- K 39 -- 9 -39-P 39- 39- P till IIIIII III I II If 111111-1-1 hillt iTTITIi7 YiliIillTrtTT L AP R�'D APPROVED WITH CONDITION(S) DISAPPROVED A N PLAN REVIEWERS NAME (SEE ATTACHMENT WITH CONDITIONS) ltillllliltitll!lIIIt1 DATE 1 14 MGM 111!11111111!!! llltll liltlltltttl! 1 11111111111111►111►111 1 11it►!llilllll►tl APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORD INANCES,.STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I COOMPENSAT CERTIFY THAT IN THE PERFC lF OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO 14CRKERIS IONN LAWS OF CAL I FO IA.tt pp APPLICANT'S SIGNATURE: r: U TITL(A I BILLING INFORMATION: Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the party desi ed below is different than the permit applicant, e.g. property owner, the party must acknowledge -his responsibility for the bilCi g yi� ture and at low. Name Mailing Address Day Phone Numbg! ) Signature EH Z3-0038 ob, 'r C&-,tt- 0,V py4024-1 I