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■ PRONE ; t --iltittllllT{ItKji Dl tlltltlittll) TANK SItE CHEMICALS 6f4R&P I+YIPREVSOUS;;F DATE UST INSTALLED T 1 39- - 1 A t 39- ' N 39- i { i 39 i 79- i Illlltttltllllttlllltll t titllllll111{11111 1 - 1 ititiltililtilllillli t H11111ti111111111 ti 1 11lIIItllttillttli Ib L 1 »� APPROVED .�_�., APPROVED WITH CONDITIONS) _ DISAPPROVED i A 1 fSE8 ATTACHMENT W=11 CONDITIONS) 1 N 1 ?LAN REVTSWERS NAME DATE -A IIII IIIIIIIIIIII I I I 1111111111111 IIIIHIII IIIHIIIIIIII111titull 1 1 11I1i11lllllttlu t1111111ttt11111tIt1 INI1111111� APPLICANT NUST PERFORM ALL MORA IN ACCOR=XT WITH SAN JOAW9W COUN`rv- ORDINANCES, STATS LAWS, AND RULES ANO 2ZGUiJITI4R:5 OF SAN JOAOUIN COUNTY rnLSC HEALTH SERVICES. OWNER OR LICENSED AGENT'S 5+GWIATURE CERTIFIES THE FOLLOWI::3: "I CERTIFY Tt%4T rN THE P$RFORMANCP OF THE WORK FOR MxZ CY_ TH2S PERMIT IS ISSUED, z SMALL V r EMPLOY ANY PERSON TN SUCH A-*"vVER AS 2O DBCONS MWECT TO WORXIk'S COMP3NSATION LAWS OP CM4FORUXA.- CO2iRACTOR15 HIRS'Xi Oft. SUBCONTRACTING SICNATUA= CERTIFIES THS FGLLOWIN&ri -2 CERTIFY THAT IN THE v"FORMANt£ OP THE WORK FOR WHICH TY!S ;-21M2T IS ISSUED, I SHALL EMPLOY PERSCN5 SU949CT TO WORKEit'S COMPENSATION LAWS OF CALIFORNIA-' j A2PL:CANT1S SIGNATURE: BILLING INFORMATION: TITLE Py -c s' d '- ( 0'm Indicate the responsible party to be billed for additional PHS -MM staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the biding by signature and date below - Name address phone number Signature,— EH 23-0038 1 NVIROM4E'W,TL IICALTU CIVX5ZON • APPLICATION FOA UWDfiAGAO 'F%NY AETROPIT, OR PIPING REPAIR PERMIT THIS PERMIT EXPIRBS 90 DAYS FROM TP5 APPROVAL BATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERM:T TYPE BELOW! TANK RETROFIT -Y. PIPING REPAIR EPA SITE U PROJECT CONTACT 6 TELEPRONS U P FACILXTY NAME L t b PHONE # '� o g 111 A C I ADDRESS W �} J � - i �► C S% L j CROSS STREET Z OWNER; OPERATOR ^, J ' PHONE # 30 S _5740 ' Y c CONTRACTOR NAME ✓f IG T� �L + PHONE w 7a7 N j Cv=&AC'_'OA ADDRESSR 4V1� CA LIC # `�1 ��l �O� i Cj:.SS fiA\ A (� GMH RZNS'JAPA GV y'...dr�w✓�l-Ci1 ILLS / ECev�nr�c1 VI p WORR.COMP. ( .3 R f C OBo 272S Oe,S� A C ( vTh-EA nVORMATION T PHONE M O A ■ PRONE ; t --iltittllllT{ItKji Dl tlltltlittll) TANK SItE CHEMICALS 6f4R&P I+YIPREVSOUS;;F DATE UST INSTALLED T 1 39- - 1 A t 39- ' N 39- i { i 39 i 79- i Illlltttltllllttlllltll t titllllll111{11111 1 - 1 ititiltililtilllillli t H11111ti111111111 ti 1 11lIIItllttillttli Ib L 1 »� APPROVED .�_�., APPROVED WITH CONDITIONS) _ DISAPPROVED i A 1 fSE8 ATTACHMENT W=11 CONDITIONS) 1 N 1 ?LAN REVTSWERS NAME DATE -A IIII IIIIIIIIIIII I I I 1111111111111 IIIIHIII IIIHIIIIIIII111titull 1 1 11I1i11lllllttlu t1111111ttt11111tIt1 INI1111111� APPLICANT NUST PERFORM ALL MORA IN ACCOR=XT WITH SAN JOAW9W COUN`rv- ORDINANCES, STATS LAWS, AND RULES ANO 2ZGUiJITI4R:5 OF SAN JOAOUIN COUNTY rnLSC HEALTH SERVICES. OWNER OR LICENSED AGENT'S 5+GWIATURE CERTIFIES THE FOLLOWI::3: "I CERTIFY Tt%4T rN THE P$RFORMANCP OF THE WORK FOR MxZ CY_ TH2S PERMIT IS ISSUED, z SMALL V r EMPLOY ANY PERSON TN SUCH A-*"vVER AS 2O DBCONS MWECT TO WORXIk'S COMP3NSATION LAWS OP CM4FORUXA.- CO2iRACTOR15 HIRS'Xi Oft. SUBCONTRACTING SICNATUA= CERTIFIES THS FGLLOWIN&ri -2 CERTIFY THAT IN THE v"FORMANt£ OP THE WORK FOR WHICH TY!S ;-21M2T IS ISSUED, I SHALL EMPLOY PERSCN5 SU949CT TO WORKEit'S COMPENSATION LAWS OF CALIFORNIA-' j A2PL:CANT1S SIGNATURE: BILLING INFORMATION: TITLE Py -c s' d '- ( 0'm Indicate the responsible party to be billed for additional PHS -MM staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the biding by signature and date below - Name address phone number Signature,— EH 23-0038 1