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APPLICATION FOR UNDEIWND TANK RETROFIT, TANK LIMING, OR PIPINGOAIR PERMIT <br /> ` THIS PERMIT IXPIRES �O DAYS FROM THE ROVAL DATE. 00 NOT '.TRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> TANK REPAIR/RETROFIT TANK LIMING PIPING REPAIR <br /> EPA SITE PROJECT CONTACT 8 TELEPHONE ' <br /> F FACILITY NAME e I PHONE ;l p <br /> A _Le <br /> C ADDRESS <br /> I <br /> L CROSS STREET ' <br /> I <br /> T OWNER/OPERATOR w PHONE R <br /> Y G, A a 9" t2-3 _ S2&S- <br /> C CONTRACTOR NAME ,/ I PHONE <br /> 0 �s-.c.� - V <br /> N CONTRACTOR ADDRESS ,. 'I C:. LIC �j �� CLASS <br /> T LlJ PC/ <br /> R INSURERC p ,)C 3738 3 q l uORK,C"•MP.niZ 41a <br /> `I35F7-� qg <br /> k C OTHER INFORMATION <br /> T <br /> 0 PHONE <br /> R <br /> 1 PHONE 9 <br /> I111111111111111111Il1i1!l1111 <br /> TANK !O TANK. SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> � ]Y' <br /> 39- <br /> A <br /> 9 A 39- i - <br /> N 39- <br /> K 39- i <br /> 39- <br /> 39- <br /> , P <br /> 1111MTFMTMT] 1111 11111ill II III I 11111ITM1111 HIIIIIII Ilmill <br /> L APPROVED APPROVED WITH CONDITICN{S} �! DISAPPROVED <br /> A ( ATTACHMENT WITH CONDITIONS} <br /> N PLAN REVIEWERS NAME 1(�4� DATE its <br /> 1111111111111111111111[1111111 11 111 11!11!11111111111111111111111111!11!111 1111111111111111 Illlllllllillll111 11!1!!11!1 <br /> APPL!CANT !LUST PERFORM ALL WORK IN ACCORDANC4 WITH SAM JOACUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGSJLATIONS OF <br /> SAN XACUIN COUNTY PUBLIC HEALTH SERVICES. ;LINER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CZRTIFY THAT IN <br /> THE PE.'.FORMANCE 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." CONTRACTCR'S HIRING OR SU8CONTRACTIMG SIGNATURE CERT!FIcS THE FOLLOWING. <br /> "I CERTIFY THAT IM THE ?ERFCRMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPE4SATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE p 3A7c <br /> 3ILLING INFORMATION: <br /> Indic3te he r-esdansible party to be billed for additionaL PHS-=HD staff time expended beyond permit payment coverage per tank. If the <br /> parry designated 'oel©w is different than the permit applicant, e.g. property owner, the parry must acknowledge .his respcnsibiLity for <br /> me 'oiLL-ing by signature and date below. <br /> Name <br /> Mailing Address <br /> Day Phone .4umner } <br /> Signature <br /> _H 33-0038 <br /> 1 <br />