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�•1 ENVIRONMENTAL HEALTA DIVISICN <br /> APPLICATION FOR LRIDERGRM'NO TANK RET20FIT, TANK LINING, OR PIPING REPAIR PER.%IIT <br /> THIS PERMIT EXPIRES 90 OATS FRC-4 THE APPROVAL DATE_ 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE HELCU: <br /> _TANK REPAIR/RETROFITTANK LINING PIPING REPAIR <br /> EPA S[TE 2 PROJECT CONTACT TELEPHONE —4( w <br /> F FACILITY NAME + PHCUIE 1 <br /> A HCl- q 577y <br /> II ADDRESS O rC t <br /> 1 1 <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR _ yI PHONE 2 <br /> 11 9-gG-1 -5 7� <br /> C CONTRACTOR NAME e/�7* e . I PHONE <br /> q CONTRACTOR ADDRESSt / CA LIC /�'7G CLASS el. }G <br /> I INSURER /� p- <br /> OTHER INFORMATION <br /> i I PHONE 2 <br /> II......IIIi((1((IIII(I((iII(I PHONE 9 <br /> 39- <br /> TANK ID 4 TANK SIZE CHEMICALS STORED CURRENTLY/PREVICUSLY DATE LUST INSTALLED <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 3q- <br /> 39- <br /> III( <br /> _ APPROVED _✓ APPROVER WITH GO201TICU(S) DISAPPROVED <br /> SES A ACWNT WITH CONDITIONS) (� <br /> PLAN REVIE'JERS NAME AM VXDATE } W <br /> ((((((((I11(II(I(l[(1 ! 1111(11111 1!111111 lllll l 111Iilllllllllil(111 11 11111III( M II III11111i11111111111111i111 <br /> PPI-ICANT MUST PERFORM ALL WORK. IN ACCORDANCE WITH SAN UCAOUIN CCUNTT DRDINANCrS, STATE LAWS, AHD RULES AND REGULATIONS OF <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SEERVICEES. OWNER OR LICZ-NSZD AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I S.ERTIFY THAT IN <br /> HE PERFORMANCE OF THE WORK FOR WHICH T'iIS PERMIT IS ISSUED, I SHALL NOT anPLOT ANY PERSON IN SUCH A .4"NER AS TO BECOME <br /> J8-:ECT To WORKE'R'S COMPENSATION LAWS OF CALIFORNIA_' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> I CrRTIFY THAT IN THE ?E-M-144ANCE OF THE WORK FOR WHICH THIS PER-41T 15 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO 'VORKER'S <br /> —4PENSATIGY LAWS OF CALJ�OR41A_" <br /> 'PLIC-ANT'S SIGNATURE: r� TITL_ <br /> NG INFORXATION_ <br /> are the resoonsible part-f to be billed for additional PHS-END staff time expended beyond permit payment coverage per tank_ If the <br /> designated below is different than the permit applicant, e_g, property owner, the party must acknowLedge this responsibiLity for <br /> iLLing by signature and date 1)elow_ j <br /> tg Address <br /> lone Number l� ` <br /> urr <br /> GON�I'IlDtJS: <br /> vis Pec+-c�ii a i-" 4Q.: - 41Z I' uLr--s vv-, acLu rtica .. <br /> 0Q38 - , <br /> �* r. ; <br /> .: - •- .rte _. -. ..fi,-r <br />