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APPLICATION POR VNDERGRO TANK IRONMENTAL HEALTH DIVISION <br /> • RETROFIT, OR PIPING REPAIR PERMIT • <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _TANK RETROFIT PIPING REPAIR <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # <br /> F FACILITY NAME <br /> A PHONE # <br /> C I ADDRESS ` T <br /> L I CROSS STREET <br /> I 1 <br /> Yi OWNER/OPERATOR I PHONE # <br /> oaa a- I <br /> CCONTRACTOR NAME I PHONE0�� <br /> O <br /> N I CONTRACTOR ADDRESS <br /> ,I, I CA LIC M I CLASS[-) <br /> LASS <br /> R I INSURER nL <br /> A I WORK.COMP.# <br /> C 1 OTHER INFORMATION i <br /> T <br /> A I I PHONE # 1 <br /> —IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII I PHONE # <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T I 39- <br /> N I 39- <br /> K I 39- <br /> 39- <br /> 39- <br /> I <br /> 9- I I I <br /> —11111111111111111111111111111111Jk1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 I III <br /> L ; �/ PROVED APPROVED WITH CgNDITION(5) DISAPPROVED <br /> N /,�/��� /� (�E� 'AC}A16NT WP,j'J,y O`• NDITIONS) 1 <br /> N 1 PLAN REVIEWERS NAME �'(/( (M.L.-J, <br /> QD J�Z,W��/�/ • 9 DATE .- <br /> —lunnuunnulnnl u n ul nl nnnlinninunull uuuuu111]1111111111nu1u�ulnnulunnnnl unn� <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 1 <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNERAS TO BECOME <br /> SUBJECT' TO WORKER'S COMPEN ION LAWS OF CALIFORNIA.• CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES TF. FOLLOWING:1 <br /> 'I CERTIFY THAT IN THE P FO CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, Z SHALL EMPLOY PERSONS SUBJECT TO WORKER'S 1 <br /> COMPENSATION LAWS OF CAL FO IA.• <br /> APPLICANT'S SIGNATURE: ,I,I� <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond <br /> permit payment coverage per tank. If the party designated below is different than the permit <br /> applicant, e.g. operty owner, the party must ackn ledge this responsibility for the billing <br /> by signature date below. <br /> N70hone number p20ef /6 Ned 3 7 <br /> Signature <br /> EH 23-0038 1pAo L0 2&&o 5e.r��. <br /> �S V <br /> <�9 �,a C71 a C) q I $ 2s <br /> a~ ate- G'z <br /> 1 <br />