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is APPLICATION FOR UNDFJRL'ZOUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br /> THIS';6KIT EXDIRES'90 OATS FROM AL DATE. DO NUT WRITE IN ANY SHADED �. INOICATG PERMIT TYPE BELOW: <br /> —TANK REPAPURETROFIT TANK LINING —L4 PIPINC REPAIR <br /> EPA SITE P _ PROJECT CONTACT L TELEPHONE t _ <br /> F FACILITT NAME r PHONE f <br /> A r L�:, rz �a 3- 7ot)3 <br /> G AOoaEss �f2o l� 41 Mr~ �:x e,Ar "5 X75 <br /> I <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR ,I PRONE t - <br /> C CONTRACTOR NAME J�/ �O PHONE tR <br /> 0 <br /> N CONTRACTOR ADORESS -'7-qc)"5 ntLY•^-��r.J^ /�i'V G_ G LLC >Y..3(S�-5310-. cf-a" eGI-v -� <br /> T <br /> R INStf2ER —�� 'G ^ WORK.fYYNP_f , . <br /> Af - <br /> C f OTHER INFORMATION <br /> T <br /> 0 t RHONE R <br /> R <br /> PHONE s <br /> 1111t1illtlllliflltltlllllllll <br /> TANK- 10 0 TAH SIZE CHEMICALS STORED CURREHTLT/PR£VICUSLT DATE VST INSTALLED <br /> 39• - / G.ri?!2� CGL <br /> T 39- ice ` <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39• <br /> 39- <br /> 1111 <br /> A]. <br /> _✓APPROVED WITH CONDITION(S) �. OISAftki 4l O <br /> A _CSEE ATTACHMENT WITH CONDITIONS) ` • ,_-'ZZ 1j <br /> N PLAN REVIEWERS )LANE bXt <br /> 1tiltiililtilpil111. 111111111111,11,t <br /> III! fill <br /> APPt ICAHT MUST PERfORM ALL WORK IN,ACCCit7ANCE WITH SAN JOAOUIN CWNTT o fURCES� tt1lTE iJdtS',hAHO RUL�T' X110 Rk`CN.ATIONS 11f <br /> SAN JOAOUIII COUNTY PML1C HEALTH SERV.ICES:: OWNER OR LICENSED AGENT'S StGHATIIRf`CERTIf1ES T'HY�EuI.=tC4 CllIMi)1 ;*f yt£RTI" NAT 19 <br /> INC PERFORMANCE Of.1ft WORK FOR WHICR;•TAIS;"IT IS ISSUED, I $HALL NOT EMPLOY"AIT;AERSDFI'!xx' i °dlAl ft AS TO SECaiE <br /> SUBJECT TO Wat Uft::&PPENSATIOH LAUVOP-MLIFORK IA•" CONTRACTOR'S HIRING OR 'SIJ AYRACTYX1L Lt�i'A�YRYCftES Tw"ftk.i OWNS. <br /> "t CERTIFY THAT 19'.UE kRFORMANC£�'OF�TRE WORK FOR WHICH THIS PERMIT IS ISSUED, i SRAL•L �1: .'f,'t �> 7N$`SU11Ad ;Td-:I�Q21C1:RlSr;... <br /> ca-inUSATION LAWS OF*CALtf NIA " '_ - <br /> f: <br /> APPL IC(Ni!s SLGNATUREt L, Ti TLE <br /> 9llltNG INFORMATION:;;• i'. .• - . ... _ <br /> Indicate the respetulblt party to be blllld for additional PHS-EMD staff time expended biyo, permit payment e6Verige per tank. If the <br /> party designated balbG ,ry different than the permit applicant, e.g, property owtor, the petty ajait a:knbwledga this responsibility fa <br /> the billing by signstUra in//d data b <br /> elowdw <br /> Nave 'SL�'k JACO" +�iY`e_ t lxrA v4 <br /> Mailing AtidreS4 'y ` "`r-� • .'�' iy .�+� �,� ,.,o T <br /> Day Phone Nurber (s��. )S;, �nn.a-1�' M-i�wLt,/r oOl ./TnP <br /> Signature <br /> . r <br /> s. um /o z PUBLIC HEALTH SERVICES <br /> EH 23-0038 post-It'•brand f ransmiral memo 7671 sot ages !`: E <br /> 3 �i__�� SAN JOAQUIN COUNTY <br /> a <br /> To From 1- i '�Jj <br /> � � la. �, <br /> Co. Co.Co. �S-z^ PAMELA S. ViOLET-1'. R.F.H.S. <br /> Dept. �/ �ffF Phones 4niur Registercd Pnvironmenml Hcalth srrnafu <br /> Fax N Fax Fv,irnnmrnt"I <br /> 11111th rlision 144 N Sim <br /> yen <br /> JAc. 011.5 I'r) Ro, ?(ti, <br /> i •.3 (2"Yi and.Gl lA st"Lmn.fn ua,nl.4Mr <br />