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WkWIRONMENTAL HEALTH DIVISION <br /> 1 <br /> r ` APPLICnTION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS -ROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE 3ELOW: <br /> /TANK RETROFIT PIPING REPAIR <br /> S?A SITE # PROJECT CONTACT b TELEPHONE # <br /> ? ?ACILITY NAMET5 C I PHONE # <br /> / <br /> A <br /> C ADDRESS /,Y�p5 ' 1/,71V/Y�&W 4N15 io <br /> = r <br /> L --ROSS STREET <br /> T OWNER/OPERATOR ?HONE # <br /> Y i , 'g 9y:? S i <br /> C I CONTRACTOR NAME !/E,,�/EQlIJ CO,v1-7voc-7.1U� ?HONE u(20 4� `i�13- 50 S g <br /> O /'1 /vV i <br /> Y CONTRACTOR ADDRESS ao�S 0 E Fri rr�c,N't CA SIC a I g 6 I CLASS A_ lQ- <br /> R _NSURER A co 2� WORK.COMP. <br /> C OTHER INFORMATION T <br /> 0 ( PHONE # <br /> Q L i <br /> ?HONE # <br /> 111111111111111111111111111111 <br /> TANK ID # I TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY i DATE UST INSTALLED <br /> 39- <br /> T I 39- 1 <br /> A I 39- 1 <br /> N I 39- 1 <br /> K 1 39- <br /> 39- <br /> 39- <br /> APPROVED <br /> 9-39- <br /> APPROVED AP OVED WI CONDITION(S) DISAPPROVED 1 <br /> ITH CONDITIONS).11 PLAN REVIEWERS VAMEOWM Ilu V V-%�A OAT E <br /> 1 <br /> —1111 111111111]1II11! IIIIIIIII 11 11 1 111 11 I1111l11lI111111111111111111111i111111111111111111 1i1111111111111111 <br /> AP?L:C?.NT MUST PERFORM ALL WORK :N A CRDANCZ WI'^?£ SAN .;OAQUIN COUNTY ORDINANCES, STATE LAWS, AND RTJLZS AND REGULATIONS OF 1 <br /> SAN .;CAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S .SIGNATURE CERTIFIES ,'HE FOLLOWING: "I CER'-:FY TWAT IN <br /> THE PERFORMANCE OF THE WORK FCR WHICH THIS PERMIT IS :SSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A SIANNER AS TO 3ECOME <br /> SU3JEC7 TO WORKER'S COMPENSAT:ON LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNA=RE CERTIFIES THE FOL:.OWING:j <br /> :ERT:FY THAT --N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS .SUBJECT TO WORKER'S <br /> CCMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: Zak -^ tt Q�G � TITLE DATE <br /> ! <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-EHD 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 /lCA.4krf" G,,, address ;t0&0 Ae,5yri(wf phone numberS2c2y 1 LS-5-05-2 <br /> Signature c�tc�J <br /> tAN'D�TI,pNS. <br /> 1. 1Jdt``t IoC.L�-i �tr�? T.�2.�,���VvlfL✓l�: <br /> EH 23-0038x. Ccl�� hours M awua ic) (ACX . <br /> S- A I t, eq k;49 Mutt d YAU* L Y-&� <br /> 4. AU yh6W VYI L)►'i-gC.t- <br /> Cora Trckeck'�A - <br /> 5• IF� - is rl -Fo � e G t-t, - -k--w tWc — <br /> ��s <br />