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r • ENVIUUNML)n AL HLAUN DIVISION <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATL DO NOT WRITE III ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> `I _TANK REPAIR/RETROFIT _TANK LINING _ PIPING REPAIR <br /> EPA SITE # PROJECT CONTACT & TELEPHONE 111441X�6 <br /> FACILITY NAME G a PIIONE # -7 OQO <br /> AEw J <br /> C ADDRESS /bNWr_o_ C O <br /> I <br /> L CROSS STREET <br /> I — <br /> T OWNER/OPERATOR <br /> PHONE # <br /> Y <br /> C CONTRACTOR NAME '— PHONE #7-09- <br /> 0 <br /> H CONTRACTOR ADDRESS ,n AN SpA <br /> R INSURER L-`./ taps �U CLASS <br /> /� UBLICCOMP-# <br /> A rT Dffl jw ux�o/bI767 <br /> C OTHER INFORMATION P.O. BOX 2009, STOCKTON, CA 5 <br /> D PHON>`Z/U'J1L"10" PHONE At <br /> R <br /> PHONE # -- <br /> 111111111111111111111111111111 ��--tt <br /> TANK 10 # TAQ A V2 CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST IiISTALLED <br /> 39- changes, See Re parka <br /> T 39- rov <br /> A 39- <br /> N 39- g L315a� E <br /> K 39- <br /> 39- -- - <br /> 39- KL-Alzrks <br /> P IIII fTT ffTfTT_ r f - fTfTfTfff illjfTTTTT <br /> L PPROVEDqq�,,�APPROVED WITH CONDIT(QN(S). - ---UTST7F0OVEp <br /> A F�4'F- TrArYIf WITH CONDITIONS) <br /> PLAN REVIEWERS NAME A 'V'1 �;1y�tCb4aL <br /> fIIiIIIIIiIIIIIIIII111Tf IIPTIIfTTT11111f1TTTTIFF�tid11�4F11fTIITrflfiTlfffTT <br /> C h is s F. a Qmission <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE I S�( M1Q 40. §DUN iY:ORD INANCE�,'SP�I} LA S ANDnPULES AND REGULATIONS OF <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. L' N1' D AGENT'$ s.LcNgL.1-- o5kT6ktdg T4 '{ULOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WI de , PtHACL`IiOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATICKIL W F C LI TO <br /> WMACM'S AIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "1 CERTIFY THAT IN TIIE PE ORM E HE R FOR WHICH THIS PCRMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WOR%:ER'S <br /> COMPENSATION LAWS OF CA LI <br /> NI - <br /> APPLICANT's SIGNATURE: T TITLE i` t> `r- Afk6eR- DATE' ? <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PIIS-EHO staff time expended beyond permit payment coverage per -.ank. 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 /> (lame `�'"� �,..�pp,. <br /> Mal I Ing Address_ ��_.f�-[;. _ ➢YpSW .'�(-( �'•�""'���� .� <br /> Vis'- �._ . _ ----- --- -- <br /> ') o-, � .c-Cr xxxir­� W/(n 300�6L-0, <br /> s) <br /> i <br />