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ENVIRONMENTAL HEALTH DIVISION <br />t APPLICATION FOR UND ND TANK RETROFIT, TANK LINING, OR PIPING WIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />_TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the <br />party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br />the billing by signature and date below. <br />Name <br />Mailing Address <br />Day Phone Number ( ) <br />Signature <br />EH 23-0038 <br />1 <br />EPA SITE # <br />PROJECT CONTACT & TELEPHONE # <br />F <br />FACILITY NAME <br />PHONE # <br />A <br />C <br />I <br />ADDRESS <br />L <br />I <br />CROSS STREET <br />T <br />OWNER/OPERATOR <br />PHONE # <br />Y <br />C <br />CONTRACTOR NAME <br />PHONE # <br />0 <br />N <br />CONTRACTOR ADDRESS <br />=CA <br />LIC # <br />CLASS <br />T <br />R <br />INSURER <br />WORK.COMP.# <br />A <br />C <br />OTHER INFORMATION <br />T <br />0 <br />PHONE # <br />R <br />illlltlllli1111111111111111111 <br />TANK ID # <br />PHONE # <br />TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />T <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />1111 <br />P <br />L _ APPROVED <br />_ APPROVED WITH CONDITIONS) <br />_ DISAPPROVED <br />A <br />(SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME <br />III IIIII III III I111III 111111111!111! 1 <br />!1l11 IIt I 11 11 1 <br />DATE <br />11111111111111111111 111111111 Il 111 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. <br />OWNER OR LICENSED AGENT'S SIGNATURE <br />CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS <br />PERMIT IS ISSUED, I SHALL NOT EMPLOY <br />ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, <br />I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: <br />TITLE <br />DATE <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the <br />party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br />the billing by signature and date below. <br />Name <br />Mailing Address <br />Day Phone Number ( ) <br />Signature <br />EH 23-0038 <br />1 <br />