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¢nua DIVISION <br /> APPLICATION FOR UNC TOUND TANK RETROFIT, TANK LINING, OR PIPINC 'AIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _TANK REPAIR/RETROFIT _TANK LINING X PIPING REPAIR <br /> EPA SITE #CAT 080026362 PROJECT CONTACT & TELEPHONE #RICHARD JOHNSON (916) 972-2418 <br /> F FACILITY NAME PACIFIC BELL PNONE # <br /> A <br /> C ADDRESS 1413 BOURBON STREET, b'PO(rim, CA. t <br /> I <br /> L CROSS STREET BLEST LANE <br /> 1 <br /> T OWNER/OPERATOR PHONE # <br /> Y PACIFIC BELL <br /> (415) 331-0924 <br /> C CONTRACTOR NAME AR(x]SON ENGINEERING, INCORPORATED PHONE # (916) 631-1646 <br /> 0 <br /> TCONTRACTOR ADDRESS 11297 COMMA ROAD CA LIC # 592010 CLASS A, B, HAZ,C-10 <br /> R INSURER DICK HARRIS INSURANCE AGENCY WORK.COMP.# <br /> A NWC 377016-04 <br /> C OTHER INFORMATION <br /> T <br /> 0 <br /> R PHONE # <br /> 111111111111111111111111111111 PHONE # <br /> 39- 11 Tdy ID # 3,000 (;AI.I AJNS CHEHLCAIS_ST [CURRENTLY/PREVIOUSLY DAVIT)1)ST5YIJALLED <br /> T 39- Ull��SS��;;LL, / ' <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P 1111 <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A S E ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> 11111111111111111111 Milliniminn in I I I I furl ly I 11111111111111 I IMITI Fi <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 AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF TNS 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 COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "1 CERTIFY THAT 1N 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: TITL DATE <br /> So� J <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PNS-EHO 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 /> Name PACIFIC BELL ATrN: RICHARD JOHNSON <br /> Mailing Address PO BOX 15038, SACRAMENTO, CA. 95851 <br />