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tNVINUNMLN1AL HLALTH DIVISION <br /> APPLICATION FOR UNDENO TANK RETROFIT, TANK LINING, OR PIPING 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 REPAIR �,VT } <br /> EPA SITE 0 I l PROJECT CONTACT 8 TELEPHONE tl 6..LCS _D k11,10 h"t <br /> F FACILITY NAME OSw CO l- Oro4i' I SI+t * 6q L1 I 1 <br /> PHONE Al Colo) a7 7 _ Z3 I q <br /> A 1, t <br /> C ADDRESS (1"1� p aGy (• RU+ uo! S JC�'tA <br /> I r <br /> L CROSS STREET p�� -� _ rck Lh. <br /> I <br /> Y OWNER/OPERATOR U C PHONE Al <br /> C.10Sd <br /> CCONTRACTOR NAME 6 Or�C k Pp- �t PHONE 41 404) <br /> D q 34 6S7S A B HAz < Iu <br /> N CONTRACTOR ADDRESS 130 RV�� ;. CA LIC X CLASS <br /> i f <br /> R INSURER V�h C TndEmh t`p (fi1Y�,v-,Ca, WORK.COMP.$ Q O Y a l ;L _o <br /> A <br /> C OTHER INFORMATION <br /> r PHONE 'W <br /> PHONE N <br /> F TANK 512E LHEHICALS STORED CURRENTLY/PREVIWSLY DA7E UST INSTALLED <br /> O ll600 4-a,Llm IL ayoK 39- <br /> 39- <br /> 39- <br /> P <br /> 1111 <br /> L APPROVED APPROVED WITH CONOITION(S) DISAPPROVED <br /> A ,, ��IJ v� EE ATTACHMENT WITH CONDlTI0N5) 1 C <br /> N PLAN REVIEWERS NAME A �.w/ �"✓ ' DATE '_-•� <br /> 11 <br /> 11111111111111111111111111 111 Fl 111 I I I I IIIII I11 I I I II II I 11 II III 111111 WWI 111111111111111111 111111 I 111111111111111 <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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." p- <br /> APPLICANT'S SIGNATURE: TITLE ��CA I t� e•e•lr DATE (U <br /> DAJID Y'N �N <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-EHO 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 must acknowledge this responsibility for <br /> the billing by signature and date below. r1r <br /> Name ® , [C� I'-'f Yb 1 iL(.V1n <br /> Mailing Address 13'.) M e-Sp <br /> Day Phone Number (_41) <br /> Signature fwl� <br /> CtA <br /> EH 23-0038 � I1II __ <br /> be 3'"P,.�1.a / ,x/ <br /> i <br />