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OCT- 7- z+ rlif 11 :20 •T ROBINSON TRUOk'IhTU IFIO 209582na6s F . 1 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> - APPLICATION FOR UNDER* TANK RETROFIT, TANK LINING, OR PIPING RA PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THEEAAPPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYPE BELOW: <br /> YANK REPAIR/RETROFIT TANK LINING - PIPING REPAIR <br /> EPA SITE PROJECT CONTACT & TLLEPRONE 0 <br /> A FACILITY NAME PHONE X f <br /> C ADDRESS l <br /> 1 <br /> L CROSS STREET <br /> I <br /> T E PERATO PHONE * ¢+ <br /> Y <br /> C CO►ITfIh.CTOfI HAM <br /> a f . pwnui 1I (? <br /> SO <br /> N CONTRACTOR ADDRESSp � CA LIC E CLASS( <br /> T <br /> A INSURER WORK. � �7 <br /> C OTHER INFORMATION <br /> T <br /> 0 PHONE Al <br /> R <br /> PHONE N <br /> 111111111![I!lllll�llIIIIIIIII <br /> TANK ID TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLER <br /> 39- Z <br /> T 39- -- - <br /> A 39- — - — - <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> 11l <br /> P ^ <br /> L APPROVED /� pROVED WITH CONDITION(S) DISAPPROVED <br /> N PLAN REVIEWERS NAME r+ (SEF,'ATTACHMEN -WITH CnNDTTinNS) DATE <br /> 111111111111111111111111111111111111 111111 11111 111111MIM11 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1'1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS iSSUE,D, I SHALL 901 EMPLOY ANY PERSON IN SUCH A MANNER AS TO 9ECOM <br /> SUBJECT TO WORKER'S COMPENSATTON LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE F9=.LOWING; <br /> "I CERTIFY tHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT' I5 ISSUED, I SHALL EMPLOY PERSONS SUBJE=CT TO WORKF7,S <br /> COMPENSATION LAWS OF GALINI ." <br /> APPLICANT'S SIGNATU I ,,, TITLE C/ L , DATE /r�_r <br /> BILLING INFCRMATIONI <br /> 1ndlcate 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 must acknowledge this responsibll[ty for <br /> the biLCing by signature and data below. <br /> Name 'Y- lr� tZ(5 1 R tJ SED A�) <br /> Malting Address 10,l To T-{! FA-), Z, <br /> Day Phone bar ) 9 li - S7f 7- <br /> Signature <br /> �/ /._ � �� lL• I�GC/Y�� �P�ywi t�L fix ` "P Li <br /> EH 23-0038 I <br /> ',& <br /> _z_/r <br />