COMPLIANCE INFO_1986-2003 - Laserfiche WebLink

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ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UND20knUND TANK RETROFIT, TANK LINING, OR PIPIN IR PERMIT THIS PERMIT EXPIRES 90 DAYS FRO14 THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: TANK REPAIR/RETROFIT TANK LINING PIPING RFPAtR BILLING INFORMATION: Indicate the responsible party to be billed for additional PHS-EHO 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 billing by signature and date below. • _ Name-� Mailing Address Day Phone Number Signature d fGL,wala EH 23-0038 _ 1 EPA SITE # PROJECT CONTACT & TELEPHONE # 74 J — F FACILITY NAME PHONE # A — C I ADDRESS ® oZ L I CROSS STREET T OWNER/OPERATOR PHONE # Y O CONTRACTOR NAME PHONE # 3.3 N T CONTRACTOR ADDRESS t.1 CA LIC # ® ®7 /_ W �o CLASS `® eQ R A INSURER ` ®[9 bS WORK.COMP.#.2 a _ ®® — C OTHER INFORMATION T 0 PHONE # R Illlntltltllntnttttttttntt TANK ID # PHONE it TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39 - T 39- A 39- N 39- K 39- 39- 39- 1 t 1111-iT(1TIT 7' ((Tf � P L A( PROVED APPROVED WITH CONOITION(S) DISAPPROVED TACHMENT WITH CONDITIONS) 17 N PLAN REVIEWERS NAME III IIIIIIH111III11111111t DATE91 11111 ll II !t� 11 11 I 1 11 ! 1ttt11 111!1 II 1111111 1111111 FIT APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORM OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNI .' APPLICANT'S SIGNATURE: TITLE TE .X 9 BILLING INFORMATION: Indicate the responsible party to be billed for additional PHS-EHO 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 billing by signature and date below. • _ Name-� Mailing Address Day Phone Number Signature d fGL,wala EH 23-0038 _ 1