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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDEROD TANK RETROFIT, TANK LINING, OR PIPING R :R 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 PIPING REP IR <br /> EPA SITE 9 PROJECT CONTACT $ TELEPHONE S <br /> F FACILITY NAME ` PHONE 9 e r <br /> A <br /> C ADDRESS ! <br /> I <br /> L CROSS STREET <br /> I <br /> T OWNER/CPERATORI} PHONE <br /> Y6,2 <br /> ~ 3 <br /> C CONTRACTOR NAM _ PHONE ///_ ' <br /> 044 _ <br /> N CONTRACTOR ADORES _ CA LIC 9 —CLASS <br /> T C 17 f <br /> RINSURER l `t`�S I WCRK.COMP.� <br /> C OTHER INFORMATION v <br /> T <br /> 0 PHONE <br /> R <br /> PHONE 9 <br /> IIIIIIIIl1111l11l1l11111lliiii <br /> TANK IO 4 TANK SIZE CHEMICALS STORED CURRENTLY/PREVICUSLY DATE UST INSTALLED <br /> 39- <br /> 3 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> 9- <br /> 39- <br /> 39P <br /> L APPROVED i APPROVED WITH CCNDITION(S) DISAPPROVED <br /> AL Jy C5EEfTtENT WITH CONOETIflNS) <br /> N PLAN REVIEWERS NAME- � --�.� r_,C/ ---.� GATE <br /> ' Ili!111111111111111I1�1111111111111111111111llllllll! 1 11111!!l111111111ii1 1T11�llllll1111{111111111111111l1C1111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOABUIN 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 /> 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 1.4CRKE.Z'S CCMPENSATiCN LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING- <br /> " C°RTIFY THAT IN THE PERFCRMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> CCMPENSA.TICN LAWS OF CALIF N A." i ? <br /> APPLICANT'S SIGNATURE: If/L TITLE I ATEA' <br /> ILLING INFORMATION: <br /> Indicate the responsible party to be bitted for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the <br /> rcy designated below is different than the permit applicant, e.g- property owner, the party must acknowledge this responsibility for <br /> .he SiIL-ing by Sjqnacure and qate below. <br /> ame <br /> ailing Address ' <br /> ay Phone Number �) <br /> ignature <br /> 'H 23-0038 f �,.f�r'�rt€,ru /D t mi/w,��` A� /a`vs 'f ca t_evr <br />