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APPLICATION FOR UNDERI10 TANK 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 g PROJECT CONTACT & TELEPHONER <br /> F FACILITY NAME "-44 ,6t4 Tr GlLirsa PHONE "(ao2) 98Z- s423 <br /> A 1 <br /> C ADDRESS Il $0 5 ValLIb LT Tr,'Je h eAw+4 + GA <br /> I �— <br /> L CROSS STREET izn <br /> I <br /> T OWNER/OPERATOR ^� 1 PHONE F C <br /> Y �IK Y�Q�IFL. olS 1 �+ GG <br /> C I CONTRACTOR NAME Tom N1AVn AL4rOchoia �' PHONE p l- /q3 -`j L40 ! <br /> o _ 1 <br /> N I CONTRACTOR ADDRESS t173S !' f(C + '!.� X�� U LIC X 388a-�7 i CLASS A <br /> l J G <br /> T yyy I <br /> R INSURER` �-� u WORK.COMP.q I, 1 dill <br /> A I wwan <br /> C OTHER INFORMATION <br /> T / 1 <br /> RW'.lh9C� �lrip/J MA"F� M[MBArIy i exoxe a <br /> PHONE $ <br /> —11111111111 <br /> TANK 111111111111111 <br /> TANK ID p TANK SIZE CHEMICALS STORED CVRRENTLY/PREVIOUSLY DATE VST INSTALLED <br /> 1 39- <br /> T I 39- I <br /> A 1 39- I <br /> N I 39- <br /> K 1 39- <br /> 111111111 I1111111111111111111111111111111111111 I11111111111111111111111111111111111111111111111111111111111111 III I I I I I I I I I I I I I I <br /> P <br /> L I APPROVED APPROVED WITH CONDITION(S) DISAPPROVED I <br /> A 1 (SEE ATTACHMENT WITH CONDITIONS) GATE I <br /> N I PLAN REVIEWERS NAME <br /> —i I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I111111111111111111111111111111111111111111111111111111111111111111111111111 <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 <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 T.iE FOLLOWING:I <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS :SSVED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA.- //� /a J/ 1 <br /> APPLICANT'S SIGNATURE: TITLE { CC J/�Y/6�i1// DATE tl Q <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. property owner, the party must acknowledge this responsibility for the billing <br /> by signature and date below. 1 <br /> MI <br /> Name je� " 6" dress 4735,C. ��5 phone number <br /> Signature <br /> EH 23-0038 <br /> 1 <br />