Laserfiche WebLink
�aG7 <br /> APPLICATION FOR UNO NO TANK RETROFIT, TANK LINING, OR PIPINAAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FRC.N THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br /> EPA SITE 1 I PROJECT CONTACT & TELEPHONE A <br /> F FACILITY NAME Z Z L PHCNE I Zog30 r <br /> A <br /> C ADDRESS <br /> I <br /> L I CROSS STREET Z <br /> I <br /> T OWNER/OPERATOR ( PHONE <br /> Y <br /> CC CONTRACTOR NAME PHCNE 3&s z <br /> N CONTRACTOR ADDRESS /-/Z / . CA LIC ! .? I CLASS <br /> T 7 l.+\ .J <br /> R INSURERI CAI WCRK.CCMP.� <br /> A <br /> 3 7-mc 00OS2- b v <br /> C OTHER INFORMATION <br /> T <br /> 0 PHONE f <br /> R <br /> PHONE <br /> lllllli11111111lI11i11I1111111 <br /> TANK IO T TANK SIZE CHEMICALS STCRED CURRENTLY/PREVICUSLY DATE UST INSTALLED <br /> 39- <br /> r 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> i l l l fT1T( <br /> P <br /> L APPROVEDAPPROVED WITH CC OITICN(S) DISAPPROVED <br /> A _ ATTACH LT' CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE 03 <br /> 111111111111111111111 it II III1 11111111111111J! I lilli11111111111 lI1111!!!1l11l1111 Ill 111111111111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN jOAGUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JCACUIN C--UNTY PU8LIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WCRK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS r0 3ECCME <br /> SUBJECT 70 WCRK:R'S COMPSNSATICN LAWS OF CALIFCRNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFCRMANC� OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PUSCNS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE oP#,gyne'-S Mfg ' DATE 7 i Oi <br /> 3ILLING INFCRMATIC::: <br /> Indicate the rescensible party to be billed for additional PHS-!HD staff tirrz excerded beyond permit payment coverage per tank. If the <br /> _arty cesigrac:j be!ou is dif'erenc than the permit applicant, e.g. property cwrer, the party mst ackrcule ge :his responsibility for <br /> the biking by signature and date beLou. <br /> Name <br /> Mai L ing AddressZQ W kv_&rx,4, Lm 'lp i CA IS L4 L <br /> lay ?hone Ntlncer ( 2JD9= ) 3�I 114 6 <br /> Signazure <br />