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LNVih-- L,,­L flr.L ❑ ulJ1SION <br /> • APPLICATION FOR UNDERC 'D TANK RETROFIT, TANK LINING, OR PIPING RI PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> -XTANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br /> EPA SITE I PROJECT CONTACT & TELEPHONE 4 <br /> �. rrt t IU <br /> A FACILITY NAME C �� <br /> PHONE <br /> C ADDRESS 1 <br /> I I <br /> L CROSS STREET l <br /> I <br /> T OWNER/OPERATOR PHONE <br /> C CONTRACTOR NAME N PHONE 9 <br /> 0C-0 <br /> N CONTRACTOR ADDRESS .1 \ D CA LIC * <br /> T vJ <br /> AINSURER / WORK.COMP. � $p�1 qc� p- <br /> C OTHER INFORMATION <br /> T 'C0. <br /> R ���� �\� b \� �`(� PHONE <br /> PHONE 0 <br /> Illllillllllllllllilllllllllil <br /> TANK 10 1 TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- L \�c�OG (nc�Sb�;,A <br /> T 39- 'L \�P � UJ• N n <br /> A 39- <br /> N 39- <br /> K 111111111111111111FUTUM III[I In 11111Fh11111111111111111111 <br /> P <br /> L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> 1111111111111111111111111111111111111111111111! II Ill II III ii III Illll I 1 III 111111 Iilllllllll111111111111111lII <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: "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 WORKER'S COMPE ON LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE P RFORMA CE OF THE WORK N�HIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CAL1 ORNIA. ' <br /> APPLICANT'S SIGNATURE: �CU TITLE �21�C C v'\clnwS,C6 DATE CJ' \�–� ? <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-EHD 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 billing by signature and date (below. <br /> Name CO <br /> Mailing Address <br />