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APPLICATION FOR UNDERGO TANK RETROFIT, TANK LINING, OR PIPING R6R 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 REPA R <br /> "EPA SITE 9 I PROJECT CONTACT 8 TELEPHONE q- ORM - /- <br /> 633 <br /> F FACILITY NAME PHONE <br /> A <br /> C ADDRESS <br /> I <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE N <br /> Y L—V <br /> C CONTRACTOR NAME na PHONE 2 4(0/ -/_0l2 <br /> 0 Ul I LJ <br /> fl <br /> N CONTRACTOR DRESS 'G LIC d / 7 CLA55A e /%Il�/ <br /> T l (7/7 L <br /> R INSURER11 WORK.COMP.i7G�. {YIQ�L�{ <br /> p �! vV IV`/ <br /> C OTHER INFO MATION <br /> T <br /> 0 I PHONE S <br /> R <br /> PHONE X <br /> nnnnunnnninnnnnr <br /> TANK ID TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- I <br /> P rtrt 1 <br /> L n APPROV APPROVED WITH CONDITIONS) _ DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME / a„ 1 DATE <br /> 111111111111111111 ITIHII III III rrruniIII III III rrriuuuuuuuu u��— rirrrurururururuu rrururnuri <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: "1 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 P . Cc' OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WCRKER'S <br /> COMPENSATION LAWS OF CA IFO NIA." <br /> APPLICANT'S SIGNATURE. TIT � (& @��_ NDATEI!��Q <br /> V <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 oust acknowledge :his responsibility for <br /> the biLgbby s'gnature and to b Lou- <br /> Name ,G//(iL�('n� �. <br /> Nailing Address /'7� <br /> Day Phone N_ <br /> r ) <br /> Signature <br /> EH Z3-0038 <br /> 1 <br />