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APPLICATION FOR UNDERGO -'ANKH RETROFIT, OR PIPING REPAIR PERMIT • <br /> A�DRESSJt)' <br /> 0 DAYS FRCM THE APPROV'-' DATE. DO NOT WRITE IN ANY S E AREAS. INDICATE PERMIT TYPE BELOW: <br /> T K RETROFIT PIPING REPAIR <br /> PROJECT CONTACT a TELEPHONEPHONE q <br /> i <br /> L I CROSS STREET <br /> I <br /> T I OWNER/OPERATORM20 i PHONE 2n sy/�J(�`/n <br /> I <br /> C I CONTRACTOR H C - PHONE - <br /> O ' <br /> N I CONTRACTOR I CA LIC q. I CLASS Rqz. I <br /> T I WORK.COMP.% - I <br /> R I INSURER <br /> A <br /> C I OTHER INFOENA .ON - I <br /> T I PHONE % I <br /> o l <br /> R <br /> PHONE % I <br /> TANK IIIIIIIII IIIIIII <br /> TANK iD q TAW:: SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLYGATE UST INSTALLED I <br /> 39- I I I <br /> T I 39- <br /> A 39- <br /> N I 39- <br /> K 39-- <br /> 39- <br /> 39- <br /> L <br /> 9-39 39- <br /> APPROVED ✓ APPROVED WITH CONDITION(S)* DISAPPROVED I, <br /> A ' ISEE ATTACHMENT WITH CONDITIONS) ((tt <br /> N PLAN REVIEWERS NAME DATE �6 0 <br /> —I III I111111111111]1liumnI]I LIII11 IIIIIFIII IIIH111111111����f� <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OwtiiR OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY RSON IN SUCH A MANNER AS TO BECOME I <br /> SUBJECT TO WORKER' COMPEN TI N LAWS OF CALLFORNZA.' CONTRACTOR'S HIRING OR SUBCO ING SIGNATURE CERTIFIES THE FOLLOWING:I <br /> 'I CERTIFY THAT IN THE PE 0YC�OF�a"HE WORE FOR WHICH THIS PERMIT IS ISSUED, I S EMPLOY PERS S SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALZ ORN <br /> APPLICANT'S SIGNATURE: TITLE <br /> BILLING INFORMATION: <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 /> appl'c t, e. . property owner, the party must acknowledge this responsibility for the billing <br /> by date below. �j <br /> Na add hone number U / -- r�(J <br /> Signature <br /> EH 23-0038 <br /> WNfl\T\Otis <br /> %CAAEn.I\F- Ivz oe oAesle- VE�EccaQ. <br /> vAc. \ 07-e tmj;s\e 7 na V-G-A`3 . <br /> 3. GWIC `18 \Nv.v_ 1,oz.cFuc). L -co <br /> 1 <br />