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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNIb-GROUND TANK RETROFIT, OR PIPING REPAIR PERM1.� <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT�ffRRIIT IN ANY SHADED AREAS. INDICATE PERMIT TYPE 89LON: <br /> TANK RHIROPIT PIPI R8 AIR <br /> EPA SITE N PROJECT CONTACT i TELEPHONE N <br /> iACILITY NAME 0 PHONE 02650 —217Z <br /> A �-9 /^ c0 <br /> 1 ADDRESS –1 "C S ® { `� , <br /> !, CROSS STREET t <br /> VOPE 0#0— <br /> Y1 <br /> T_ /�._ y <br /> C ' CONTRACTOR NANRC-rteKIC]G 3T-R�%©vU •. Lyy-y-y.{� <br /> - _t=T ,K' JNO" E1 pc-Y6�! 8333 <br /> R CONTRACTOR ADDRESS ) Q �NJO, / _ I CA LIC N CLASS <br /> T k / I <br /> 0. INSURER NORK.COMP.O c9c) G I F7f y <br /> A I OTHER INFORMATION T I V ! \v <br /> 0 PHONE E <br /> R <br /> —{IIIIIIIIIIIIIII�I�II�I�II PRONE N <br /> TANK <br /> TANK ID M T SIZE � CHEXICALS STORED CUARENFLY/PREVIOUSLY DATE VST INSIALLEO <br /> 39- <br /> T 39 IQ�'•�-1 <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 9-39- f <br /> 39- � Illllllllllllllllllllllllillllllllllllllli <br /> )III <br /> P <br /> APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A )SEH ATTACHMENT WITH CONDITIONS) ♦ Z 0Z <br /> PLAN REVIEWERS NAME DATE <br /> IIIIIIIIIIIIIIIIIIII 111111 I II I� <br /> PLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN <br /> '.NE PERFORMANCE OF THE WORK FOR WXICH THIS P RMIT IS ISSUED. I SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS F I ORNIA.' COMBACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:) <br /> CERTIFY THAT IN THE PER CS OP 8 OR POR WHICH THIS PERMIT IS ISSUED, I SM L EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF PORN �� � <br /> APPLICANT'S SIGNATURE: TIT'L�IETr-C; 'Vy1J DATE 6-/Y-�Z <br /> BILLING INFORMATION: ��-�r na I� 1'(?(�Vift1 Cut, A ° Ingpe�f-��5 . A II eaA�;p ,F r»us�- <br /> Indicate the responsible party to be billed for additional PHS-EHD 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 party must acknowledge this responsibility for the billing <br /> by signature and date below. <br /> Name�"' �etLA address 2/'FS�I/r�V(F/ b phone numberlCq —95?—'792- <br /> Signatur xx <br /> E-H 23-0038 <br /> 1 <br />