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APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br /> THIS•PERMIT EXPIRES 90 DAYS FROM THE 0OVAL DATE. DO NOT WRITE IN ANY SHADED A* INDICATE PERMIT TYPE BELOW: <br /> _TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br /> EPA SITE % PROJECT CONTACT & TELEPHONE % <br /> F FACILITY NAME PHONE % <br /> A <br /> C ADDRESS <br /> I <br /> L CROSS STREET <br /> 1 <br /> T OWNER/OPERATOR PHONE % <br /> Y <br /> C CONTRACTOR NAME PHONE % <br /> 0 <br /> N CONTRACTOR ADDRESS CA LIC % CLASs <br /> T <br /> R INSURERWORK.COMP.% � <br /> A <br /> C OTHER INFORMATION <br /> T <br /> 0 PHONE % <br /> R <br /> PHONE % <br /> TANK <br /> 1I1!!!1[ll11111111111!!11 <br /> LANK !D % TANK 512E CHEMICALS STORED CURRENTLY/PREVIOUSLY 00.7E UST iNSiALLE0 <br /> 39- <br /> 3 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P 1111 <br /> L APPROVED APPROVED WITH C0NDI7ICN(S) DISAPPROVED <br /> A ATT CHMENT WITH CONDITIONS) I" <br /> N PLAN REVIEWERS NAME /17 I'.IM OD I\SA D DATE <br /> 111111111111111111111 HIM IIII IIIIIIIIIII 1 I I 1 111111 II 111 1! 1111111flIT11111111111111II 11111111111 I IIIII 1 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOACUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JCAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AG'c4T'S SIGNATURE CERTIFIES THE FOLLOWING: "1 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 CCMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE DATE <br /> 3ILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-"c HO 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 bitting by signature and date below. <br /> flame <br /> Mailing Address_ K ADL^ nw l rthl S T LA, C•rt 'tS Z�Z - <br /> Day Phone Number <br /> Signature <br /> EH 23.003 <br /> 1 <br />