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` r APPLICATION FCA UNI-0IINJ TANK RETROFIT,, OR PIPING REPAIR PERMIT • <br /> :'HIS PERMIT EX?IRES 90 DAYS FROM TF_: APPROV: DATE. DO NOT WRITE IN ANY SHADED AAFAS. INDICATE PERMIT ITP£BE[OW: <br /> _TANK R_::OFrr PI2- jw <br /> EPA SITS i PROJECT CON7 I FACILITY NAME <br /> T <br /> C ADDRESS <br /> I <br /> Z. I CROSS STREET 1 <br /> I <br /> 2 OWNER/OPERA'TOR <br /> c ; CONTRACTOR NAMEI PHONE iAkio 17j. <br /> L <br /> N I CONTRACTOR DRESS I CA LIG i / <br /> T LJ <br /> R I INSURER - I WORK.COMP.i <br /> A <br /> C OTHER ZNFOIi.VATT_ON I <br /> T <br /> O I PHONE 8 1 <br /> R <br /> PHONE i <br /> —�i111iI;111{IIIIfill IIIIIIIIIIII <br /> TANK ZD C TAti:; SIXE CHEMICALS STORED CURRENTLY/PREVIOUSL"( DATE US INSTALLED <br /> 1 <br /> 39-- <br /> 39-- <br /> 39- <br /> N <br /> 9-39-39-N 1 39- <br /> 39-- <br /> 39- <br /> 39-_ <br /> 9-39-39-39- <br /> --1111111111111111111{111111111111III1111{111111111111{Illillllllllllllll{Ill{1111{11111IIII11111111I1111111111111111111111111111 <br /> L 1 APPROVED APPROVED WITH CONDIZ-ON(S) DISAPPROVED 1 <br /> WITH CONDITIONS) / 1 <br /> N 1 PLA.v REVIEWERS NAME DATE J�� I'�O Z 1 <br /> —Iitlllllllllllll1i11111I1 lllllliIIIIIit11T1111tII11111I1{11111!{IilllllIII illllllllllllllilllllllfHI11111111111111111111111II <br /> i <br /> APPLICANT MUf PERFOFN ALL WORK IN ACCORDANCE "ZZi SAN JOAQUIN COtMIT OPDIMANCES, STATE LAWS, AND RULEN AND REGULATIONS OF � <br /> SAN JOAQUIN COUNTY PUBLIC HE 1.4 SERVIC=S. C:\=R OR LICENSED AGFM'S SIGNATURE C�IFIFS THE FOLLOWING: 'I CERTIFY THAT IN 1 <br /> T!4. PERFORMANCE OF THE WORK FOR iDILCH THIS PF.MT IS ISSUED, I SIiA1.L NOT r?1PLOY ANY PERSON IN SUCH A MANNER AS TO BECOME, 1 <br /> S'JBJIcr TO WORATR•S COMPENSATION LAWS OF CALIFORNIA-' CONTRACTOR'S HIRING OR SUBCONLR MXG SIGNATURE CERTIFIES TAE FOLLOWING:1 <br /> '_T CERTIFY THAT IV IN£ PER vCE OF THE WOR_: FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT 'I'O WORKER'S I <br /> COMPENSATION LAWS <br /> APPLICANT'S SIGNATURE: �'^� V TZE (r(& / <br /> BILLING INFORMATION:' <br /> Indicate the responsible party to be billed for additional PHS-EMD staff time expended beyond <br /> per-mit payment coverage per tank. If the party designated below is different than the permit <br /> applicant, e.g. property owner, the party must acknowledge this responsibility for the billing <br /> b'v signature an ate below. <br /> Na /(R"`�css — � /5t46ne numbers(!/ - <br /> Signature <br /> EH 23-0038 Covrtuci D� hnis Cc�tAv�yq at �2Dq ) 4ul -3451 11 <br /> A v v a,,9 e ave i ns pe(-'hr cry p4- -k nevi/ GP t- . <br /> 2. Allow L6 hvwr >1o+ice, Ay- "I inCpt-C t1" A fff)i"tWwAjb <br />