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HEALTH. DIVISION <br /> : APPLICATION FOR UNDERG9 TANK RE'ROFIT, OR PIPING REPAIR PERMIT • <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. JON -WRL^c IN ANY SHADED AREAS. INDICATE PERMIT TYPE 9ELOW: <br /> _TANK RETROFIT PIPING REPAIR <br /> EPA SITE % ! PROJECT CONTACT 6 TELEPHONE <br /> FACILITY NAME I / � \ L1[.oip PHONE/%'Mq-8378 <br /> ADDRESS <br /> CROSS <br /> •P•�{'�\�b�K YF� ��� vT�-EL �'"l--( �3 �1_.' <br /> 1 <br /> CROSS STREETAl <br /> 0 PSRATOR PHONE % <br /> CONTRACTOR NAME , --ONE q <br /> Mal <br /> N CONTRACTOR ADDRESS j / / LA LIC %, C:":SS�� � <br /> R INS- 8< <br /> "7 I WORK✓.^.CMP.:� <br /> i /+ <br /> C OTHER :NFORMATION <br /> PHONE % <br /> R <br /> I I ?HONE % I <br /> 1111111111111111111tlllllllitlll <br /> TANK J .'u\K S'2E "'E�MI�C � OREDp�CJR.°YN�T�L/y%�P -/`)��r 0�/S�LY I DATE UST INSTALLED <br /> T 1 39- <br /> .4 1 39- t <br /> `I 1 39- t <br /> r. 1 39- <br /> 1 39- t <br /> 39- I I I <br /> I I I I I I I I I I I I III III Fill 111111[Ili <br /> 11111111111111111111Y I I1111I111111111111111111111111111111111111111111111111111111111I1111111I <br /> APPROVED APv'CVED WITH-4CNDI^-ION(S; DISA?PRCVED 1 <br /> {/'�� (SEE C.,NEN�1T WIP,- CONDITIONS) � <br /> N ( PLAN REVIEWERS NAME DATE <br /> 1111111111111111111111111111111 I I III IIl I I I I I I I rTI I I IIIIIII1111111111111i111111111111111111111111111111111111111 Illi <br /> APPLICANT MUST =-F-CRM ALL WORK IN ACCORDANC' WI:'.i SAN JCAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COIID_Y P.3L:C HEALTH SERVICES. PWNER OR LICENSED AG'ENT'S S:GNA^'R: CERTIFIES THE FOLLOWING: "i CERTIFY .:AT IN <br /> C±E PERFORMANCE OF THE 14ORK FOR WHICH .nS RMIT IS :SSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER PS TO SECOME <br /> I JBCECT TO WORKER'S COMPENSATE N_'.AWS_ iFCRNIA." =RACPOR'S HIRING OR SUBCONTRAC-:NG SIGNAT'RE CERT:. ES HE FOLLOWING:I <br /> ___.,.r FY THAT v PERFO CJ OF W R.0 FOA WF THIS PERMIT IS ISSUED. I SHALL RMPLOY-PERSONS 5'JBSEC= 7 WORKER'S <br /> CMPENSATION LAWS IF Q <br /> i?PLC..N.'S S:G`.A ZE:�/\�� _T-: E" DATE <br /> 3ILLING INFORMATT_ON: <br /> Indicate the responsible party to be billed for additional PES-EED staff time expended beyond <br /> permit payment coverage per tank. If the party designated below is different than the permit <br /> applicant, e.g. property owner, the Darty must acknowledge this responsibility for the billing <br /> by signature and date below. <br /> Namer' q ^ /{S, addresst4k! (j F-�F.— ghene number <br /> Signature ��� <br /> 3E 23-0038 <br /> 1 <br />