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ENVIRONMENTAL HEALTH DIVISION <br /> j - ( APPLICATION FOR UNDIUND TANK RETROFIT, TANK LINING, OR PIPING&IR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE SELUW: <br /> _TANK REPAIR/RETROFIT _TANK LINING _ PIPING REPAIR <br /> EPA SITE # I PROJECT CONTACT & TELEPHONE # I K <br /> F FACILITY NAME _r PHONE <br /> A <br /> C ADDRESS <br /> I �J <br /> L CROSS STREET <br /> 1 <br /> T I OWNER/OPERATOR % PHONE # _ <br /> Y <br /> C CONTRACTOR NAME /T�r/�/I �5' PHONE #!^�y V 27 <br /> O ' 'l ✓�t� l <br /> N CONTRACTOR ADDRESS CA LIC # CLASS 7 / <br /> T / <br /> R INSURER `�' WORK.COMP.# <br /> A LJ l "I <br /> C OTHER INFORMATION <br /> T <br /> 0 PHONE.# <br /> R <br /> 111111111111111111111111111111 PHONE # <br /> TANK ID # TANK SIZE / CHEMIGCALS <br /> STORED CURREENTLY/PREVIOUSLY 0 T/E�USYT INSTALLED <br /> 91 <br /> T 39- I �YY <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P 11111111111111 Ili I fill III If 11 F <br /> L _ APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (S E ATTACHMENT WITH CONDITIONS) p <br /> N PLAN REVIEWERS NAME GF-/G if..cy' DATE <br /> 1111111111111111111111111111 I ill 1 11 III II li�T 1 1 1 IIIllllllll 1 ill 111111 1111 IIIIIIiIiI I it 11 1111 <br /> APPLICANT 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 AG'ENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FCR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAK OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "'. CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> CCMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: 11\ J .�J.,.— TITLE DATE <br /> ILLING INFORMATION: <br /> ndicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the <br /> arty designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br /> ie billing by signature and date below. <br /> a --V\ <br /> m \ GQ G <br /> .ailing Address 1 � � <br /> :ay Phone Numb <br /> e <br /> r <br /> (1 �i✓ ` 6+�� `t" — 0(� <br /> ignature C XVNI11��y',./ L <br /> _3 23-0038 GOf.1d/7'7�✓3 I <br /> �� AGG APP�h�'iEr�Ts s'/✓AL�L Bf�AD� a/P /s�2S �� AOI�A,I�CE <br /> 1 <br />