Laserfiche WebLink
APPLIC4TION =C2 UA7ERGROUND ':;NK RETROFIT, OR PIPING -REPAIR PERMIT <br />IiIS ?ERM): EX?: -RES 90 DAYS FRCM TKE A?PROV:.= DATE. DO NOT %RITE IN AN't SHADED AREAS. INDICATE PERMIT TYPE 9ELOsJ: <br />_YA.KK 1L.r-OFZT PIPING REPAIR <br />ZPA SITS X PROJECT CONTACT iTFLEPSCN2 a <br />'ACILI:Y NA?17- <br />ADDRESS <br />O J O <br />I I(tvo <br />I, I CROSS STREET' <br />Z , <br />T I OWNER/OPERATOR <br />C i CONTRACTOR NAME <br />O <br />N 1 CONTRACTOR :.DDR <br />rLY' T r YVl 1 I U LIC 3 <br />I lJ <br />R I INSURER � /^ <br />A l� <br />(: I OTHER INFOR?'A ZON <br />T <br />o J <br />R i _ <br />PHONE ' J(0 / - 97T7 <br />1 <br />j <br />1 PHONE 6 <br />i <br />?HONE 3 <br />C�C� I CLASS <br />I WOR[_COMP_S/1^^I1 <br />I PHONE 4 <br />1 I PHONE 2 1 <br />,,,,,Taf f a,,fa, 1, 1,,,■ 11111 afif <br />euaa,u,au�u„au,uaaa <br />TANK ID 9 T:+.�_; SIZE CHEMICwS --ED=—Y/PFEVIOUSLZ DATE US. INSTALLED <br />1 <br />39- <br />39-- <br />39-_ <br />9-39- ! <br />1 I <br />3+ I 39- <br />39- <br />39- <br />11111111 IIIHII I III I IIIIIII If 1111 fill [if III I If IIIII <br />9-39 11111111II1tt111IIIIIIIII1IIf1111fill[ifIIII1fIIIII IIIIlIlli111IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII� <br />I, 1 APPROVED APPROVED WITH CWDI —ON(S-FV DISAPPROVED i <br />/ ,1y', E ATT WITH CONDI 'IONS) t <br />.I 1 ?LAN RE VIzaER_S :LAKE / e- YW \ I% i �' l V l+' l� DATE l <br />-- IIIIIIIIIIIIIIII(111111 11111 1111 1111t1 1111111illltill i11I1111I1illIII11II111111I11t1itillltiiti ! tlt 1 II! II1111111i <br />a??LICANF MUS: 2ERFORH ALL WORX IN ACCCRDA_^IC< -I:T[ SAN JOAQUIN COIM'f O?-DINANCFS„ STATE LAWS, AND .'t(TLF_S ,ND ,'tER. ILATZONS OF ( <br />t <br />SAN JOAQUIN C7VNCY PUBLIC KEAL:i Sc�RVICzS. GL'\=� OR LICENSED AGEN[•S SiG;tATJRE C-RTZFIFS THE FOW,NG= 'Z C�2I, FY THAT IX j <br />PEFFORMANC= OF THE WORK FOR 4HICH THIS ISSUED, I Sr'UL NOT j 7PLOY ANY PERSON IN SUCH A .`SANNERi AS TO aECOME. I <br />SU9J£CT TO WORI--R'S COMPENSATION LAWS OF CaI.==O.ZNIA_- CONTRACTOR'S HIRIVG OR SUBC0NT3ACIZNG SIGNA:TIRE CERTIFIES THE For -LOW -11 -:c- <br />-I C`_'RTIFY TS:.: Iv THE PERFORM;LVCE OF THE WGRX FOR WHICH THIS PERR)T I5 ISSUED, I SHALL EMPLOY PERSONS SUBJECT 7o WORKER'S ) <br />CJMRENSATION JHS OF CALIFO A . <br />A?PLICA"S SIGNATURE: <br />MTI W,C/Ii�� .i+DATE (1i+ <br />BILLING INFORMATION_ <br />i=ndicate the responsible party to be billed for additional PHS -EMD staff time expended beyond <br />jz>e=-mit payment coverage per tank- If the party designated below is different than the permit <br />applic//t, e -g. property owner, the party must acknowledge this responsibility for the billing <br />by si attire kand date below. <br />Nam ��t�ress 1 phone number -' <br />S _gnature <br />Ak <br />E:H 23-0038 <br />