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.� ENVIRONMENTAL HEALTH DIVISION <br /> i <br /> APPLICATION FOR UNDER ND TANK RETROFIT, TANK LINING, OR PIPING R R PERMIT <br /> l <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> 4 <br /> TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br /> EPA SITE # CPROJECT CONTACT & TELEPHONE # <br /> F FACILITY NAME PHONE <br /> A <br /> C ADDRESS <br /> I l�0 <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR _ PHONE <br /> Y A(a _ L`S�(v <br /> C CONTRACTOR NAME PHONE \ <br /> # <br /> O "SCS— <br /> N CONTRACTOR ADDRESS l ` � t r CA LIC # \;� �v CLA S <br /> T <br /> R INSURER �5 WORK.COMP.#. <br /> A <br /> C OTHER INFORMATION <br /> T <br /> 0 PHONE # <br /> R <br /> PHONE # <br /> 111111111111111111111111111111 <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- u e <br /> T 39- <br /> A <br /> 9 A 39- <br /> N <br /> 9 N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P 1111 <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A ,(('77 n(� yn ,'y _ (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME�n(�\1 .`YYM _k% DATE - <br /> 1111111111111111111111111 11 1111111 1 1111 1 1111111 111111111 1111 11111 a 1111111111111 111111111111111111111111111 <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 COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORVI.A.16 <br /> APPLICANT'S SIGNATURE: TITLE E vi DATE S' <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 /> C ^� <br /> Name <br /> Mailing Address <br /> Day Phone Number <br /> Signature <br /> EH 23-0038 <br /> 1 <br />