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E 26-1998 1:d8PM FROM qw 90 ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE.. DONOTWRITE IN ANY SHARED AREAS. INDICATE PERMIT TYPE BELOW: TANK R£PAIR/REYROFITm-UL—TANK LIVING PIPING REPAIR PROJECT CONTACT t TELEPHONE 0 Lo K YNC. PHONE Is L1 LIC S CLASS NjLoI PHONE PHONE 0 tlIIIlUiilIIII111!]iiiilIllii - � TANK IO S TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED S9 - T 39- A 39- N 39- Y idih 39- 39- IIII P L APPROVED WITH ITU CS) DISAPPROVED A (SFE ATTACHMENT WITH ITt ) N PLAN REVIEWERS NAME DATE ! III III 1111111111111 I11MI !! 1!111! 1 ! 1111 1III APP.ICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JO=IN COUNTY ORDIMANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER Olt LICA 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 AIiT PERSON IN SUCH A MANNER AS TO BECK SUBJECT TO WORKER'S COMPENSATION LAWS Of CALIFORNIA.• CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:' "I CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH THIS PMIT IS ISSUED, I SMALL EMPLOY PERSONS SUBJECT TO WORKER -S i COMPENSATION LAWS Of CALIFORNIA." APPLICANT'S SIGNATURE: �/ o`nTITLE /1'MIJ DATE WV4 BILLING INFORMATION- Indicate NFOR NATION: Indicate the responsibte party to be bitted for additionst PRS -EER# staff time expoife beyond permit payment coverage per tank. If the party designated betox is different than the permit app(icant, e.g. property owner, the party aunt acknowledge this responsibitiry for the bitting by signature and date beton. ]� Hamte.1> GCS ROnl;ftcnT Mailing Address - OaY Phone Number < )_ Signature ;H 23-0038 I EPA SITE X Y•® F FACILITY NAME A C ADDRESS I L CROSS STREET { I TOW NI!A/OPERATOR Y C CONTRACTOR MAKE 0 N CONTRACTOR ADDRESS T R INSURER A C OTHER 1NFORMUON T 0 R PROJECT CONTACT t TELEPHONE 0 Lo K YNC. PHONE Is L1 LIC S CLASS NjLoI PHONE PHONE 0 tlIIIlUiilIIII111!]iiiilIllii - � TANK IO S TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED S9 - T 39- A 39- N 39- Y idih 39- 39- IIII P L APPROVED WITH ITU CS) DISAPPROVED A (SFE ATTACHMENT WITH ITt ) N PLAN REVIEWERS NAME DATE ! III III 1111111111111 I11MI !! 1!111! 1 ! 1111 1III APP.ICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JO=IN COUNTY ORDIMANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER Olt LICA 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 AIiT PERSON IN SUCH A MANNER AS TO BECK SUBJECT TO WORKER'S COMPENSATION LAWS Of CALIFORNIA.• CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:' "I CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH THIS PMIT IS ISSUED, I SMALL EMPLOY PERSONS SUBJECT TO WORKER -S i COMPENSATION LAWS Of CALIFORNIA." APPLICANT'S SIGNATURE: �/ o`nTITLE /1'MIJ DATE WV4 BILLING INFORMATION- Indicate NFOR NATION: Indicate the responsibte party to be bitted for additionst PRS -EER# staff time expoife beyond permit payment coverage per tank. If the party designated betox is different than the permit app(icant, e.g. property owner, the party aunt acknowledge this responsibitiry for the bitting by signature and date beton. ]� Hamte.1> GCS ROnl;ftcnT Mailing Address - OaY Phone Number < )_ Signature ;H 23-0038 I