Laserfiche WebLink
APPLICATICN FOR UNDER= TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FRC.M THE Al VAL DATE. 00 NOT WRITE IN ANY SHADED AREAO—NDICATE PERMIT TYPE BELOW: <br /> TANK REP ] TROF __TANK LINING _ PIPING REPAIR �0 <br /> EPA SITE » PROJECT CONTACT & TELEPHONE » <br /> FACILITY NAME PHONE <br /> e a� (a <br /> ADDRESS C _Q <br /> I G � of <br /> L CROSS STREET <br /> I .57 <br /> T OWNERF6PER4-&=- PHONE <br /> OI CONTRACTOR NAME : /r C© -n Q 7Cl - n e • PHONE Q 9 1- 3 3 <br /> N i CONTRACTOR ADDRESS i/r��� / W, Q.'yYL. /JN r V Q I G L!C »A �z G CLASS <br /> R i INSURER 12 G � �tL✓ JY` D•717 Y" e 1I�CI. /" #1 (- 3/✓ frt vaRK.Cr,MP. ��Q-oTto 43TT�/7��9'7 <br /> C OTHER INFORMATION OO A O <br /> T GC <br /> 0 i PHONEo ql S D <br /> R IJJ O <br /> PHONE » <br /> ' 11!11!1}111111IfI1111111111IIt <br /> TANK ID TANK SIZE I CHEMICALS STORED CURRENTLY/PREVICUSLY i DATE UST IHSTALLs0 <br /> 39- i <br /> A 39- <br /> N39- <br /> K 39-- <br /> '9- <br /> 39- <br /> L <br /> 9- <br /> 39-L APPR EDAPPROVED WITH CCNDITICU(S) DISAPPROVED <br /> A ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAM 0 DATE L Avs <br /> I111111l1f11I11}fllllil 11! illllllll 1111i!! !111111!! i1111f111111!l11111! I1li1111i11I1111111 11 1111111llilillllllllli <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> I SAN JCACUIN 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 COMPENSATICN LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUSCCHTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I C-t'RTiFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO 'JCRKER-S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> Zi APPLICANT'S SIGNATURE: TITLE o 2 G� 9't DATE I l S-`I <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-=HD 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 /> Nailing Address <br /> Day Phone Number ( ) <br /> Signature <br /> EH Nz-0038 <br />