Laserfiche WebLink
c <br />A <br />C <br />L <br />i <br />T <br />Y <br />�ik.e c,o�'� <br />ENVIRONMENTAL HEALTH DIVISION <br />.APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PE? -41. TYPE 3ELOW: <br />E'PA SITE <br />-ACILIT'I NAME <br />�d5 <br />.ADDRESS <br />/ M-3 <br />=ROSS STREET <br />OWNER/OPERATOR <br />IVtde <br />RETROFIT PIPING REPAIR <br />PROJECT CONTACT & TELEPHONE 4 <br />PHONE <br />4&h, j c-,- (! � -- i <br />3 SOS <br />PxorrE02011 <br />C CONTRACTOR NAME/�ErtkiE�soN �O/J+76I.VC-rIC1� ?HONE S �� �(�7_ 5os g <br />0 <br />N CONTRACTOR ADDRESS -2C7E f�� ���. I CA LiC 1 I '� CL,1sS A <br />i tY u <br />R INSURER A eo rZjWORK. COMP. <br />C OTHER INFORMATION <br />T <br />+ ?HONE 4 <br />?HONE i <br />—1ilfllillillANK Z 1111111111111, <br />TANK ID X TAN7K SuE CHEMICALS STORED L'URREYiTLY/PREVIOUSLY DATE UST INSTALLED <br />1 19- <br />T 1 39- <br />A l 39- 1 <br />N 39- <br />K f 39- <br />39- <br />19- <br />APPROVED <br />9- <br />39-APPROVED INAPPROVED ATH CONDITION(S) DISAPPROVED 1 <br />CONDITIONS) <br />:11 ?LAN REVIEWERS NAME DA E <br />—llfi1111111111111i11111111111ltillll 11111111 111111!11111111111111111111111111111111111111111l11111t111111111f111ti1i11111� <br />AP?LIC.ANT MUST PERFORM .ALL WORK iN ACCORDANCE WI -11 SAN ;OAQUIN COUNTY ORDINANCES, STATS' LAWS, AND RULES AND REGULATIONS OF <br />SAN :OAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />PERFORMANCE OF THE WORK -0R WHICH :HIS PERMIT. IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A :'TANNER AS . 3ECOME <br />SUBJECT TO WORKER'S COMPENSATION :,AWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE C.RTIFIES THE FOLLOWING <br />_ryT:?Y THAT iN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: ©f l/^t� C� O��% TITLE %��I//7/¢�'l__ DATE <br />i <br />BILLING INFORMATION: <br />Indicate the=esponsible cart, <br />,r to be billed for additional PHS -HHD staff time expended beyond <br />permit payment coverage per tank. If the party designated below is different than the permit <br />applicant, e.g. property owner, the party must acknowledge this responsibility for the billing <br />by signature and date below. <br />Name Ile-xklers'" Cc,,,.5 . address ;Zo&-0 Foe& i(>yt' phone number(2t�y-ig <br />nature <br />EH ?3-00384-. Cam. kOU.✓S IVA 'FIC' <br />3. 11 y u 1 n sta j.ed TwWb e u,(. 1 5ff-d <br />q. <br />Coro v o d�aco( <br />os � <br />5,1f 4�uS !s 4D 102 ftel*VlkWk'(9f�e <br />?re bsi &m �Gj �t�c D ✓ Ct� u z` �� vY � use . <br />