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ENVIRUNMENIAL HEALTH DIVISION rr <br />e APPLICATION FOR UNDERGR TANK RETROFIT, TANK LINING, OR PIPING REP ERMIT <br />THIS PERMIT EX I_RES 90 DAYS FROM THEAPPROVALDATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />✓ TANK REPAIR/RETROFIT TANK LINING _ PIPING REPAIR <br />LLING INFORMATION: <br />:dicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the <br />:rty designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br />e billing by signature and date below. <br />^ding Address _ CLQ<�(/,r••.{t �rraS�r 7`Cl ��i%ar L. <br />�' �� �r -i <br />EPA SITE # <br />PROJECT CONTACT 8 TELEPHONE # <br />F <br />FACILITY NAME <br />A <br />C <br />Ia.J�lc <br />ADDRESS <br />N. G1�i <br />L <br />I <br />CROSS STREET <br />T <br />OUNER/OPERATOR PHONE # <br />Y <br />/ <br />i:2 i\ n / ac - r <br />C <br />CONTRACTOR NAME C PHONE # <br />0 <br />? C. <br />N <br />T <br />CONTRACTOR ADDRESS ` <br />CA LIC # ei✓ <br />R <br />A <br />INSURER T" <br />T <br />WORK.COMP.# C)' L <br />C <br />OTHER INFORMATION <br />T <br />R <br />PHONE # <br />TANK 10 # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />T9 <br />- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P I l I ! 17 TIfITiTTTTT <br />L APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br />A /-----°' SE ATTACHMENT WITH CONDITIONS) <br />cp �b <br />N PLAN REVIEWERS NAME <br />/,.•a�"�ii DATE / <br />ititfutllltiltltttl ! iifiTTTiT�i �fFTTi1Tl�Filf! l t ! 111MMUM111111 I I 11111111111111111111111 fill <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. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY 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 TH ERFORMAHCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATfON LAWS 0 CAL R�tIA " <br />i /�- <br />APPLICANT'S SIGHAT E: ld �- TITLE � > \(V0 to w� DATE <br />LLING INFORMATION: <br />:dicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the <br />:rty designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br />e billing by signature and date below. <br />^ding Address _ CLQ<�(/,r••.{t �rraS�r 7`Cl ��i%ar L. <br />�' �� �r -i <br />