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' May 24 01 00: 12a F OUMZICKER 1 2f 537 1573 p. 4 <br /> _:.✓_eOA::eNi wL eei.�H JCI=S=.::: <br /> APPLICATION FOR UNDERGROUND 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 Y PIPING REPAIR <br /> EPA SITE K 1 PROJECT CONTACT & TELEPHONE A <br /> F FACILITY NAME �r _- ) � �' O PHONE R Z 3 <br /> Ir DEESa' <br /> L I CROSS STREET I <br /> I <br /> T I OWNER/OPa R PHONE 2 3 <br /> G <br /> C I CONTRACTOR y�h z P r / le,G.,4C y,j� PHGNE a ZU�7 S 3g -G 43 3////// <br /> Ti CONTRACTOR ADDRESS /.J�k I3IU (may G?lam{. I CA LIC R ,661 �6� I CLASSe,-IO �A <br /> R I INSURER&a/GCJYz I.3 � I WORK.COMP.A <br /> AI14) I <br /> C I OTHER INFORMA ON I I <br /> O I I PHONE k I <br /> R I PHONE # <br /> TANK <br /> -II111111111I11111111111111I <br /> TANK !D X TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> A <br /> N 1 39- I <br /> X I 39- I <br /> 1 39- i I <br /> 39-- <br /> --11111111111111111111111111111111111111I11111111111y1I1111111111111111111111111 111111 11 Illl 1111111111111111IIIIIIIIIIIIIIII <br /> P <br /> L 1 APPROVED APPRO D WITH WITH CONDITIONS) <br /> O 1 <br /> AI <br /> N 1 PLAN 0.EVIEWERS :1 DATE <br /> —111111111111111111111 II111111 11 1 I 111 IIIIIIIIIIIIIIIIIIIIIIIIIIIIII11111111111I1-61,2.5 <br /> Illllllllllllllllt <br /> APPLICANT MUST ?ERFORM ALL WORK IN ACCOROANCE 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 FOLLONING: '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 THE FOLLOWING:I <br /> I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHIOH THIS PERMIT 15 ISSUED, I SHALL EMPLOY PERSONS SUHJELT TO WURKBR'S I <br /> COMPENSATION LAWS OF CALIFORNIA.- <br /> APPLICANT'S SIGNATURE: iGN F� !/!i(�TM �..//— TITLE lDATE <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PAS-EBD 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. <br /> Name ' ddress J j t] phone number Zd 9 2✓ l V s�} <br /> SSii�gnna�tuurge <br /> EH 23-0038 ►)P�,r pl�Wt4 CaWPX� G�l '1 I�h2uX-�n 6Y`--hI2�161,-K�a. <br /> �tw(/��s to r�l°it►tsaffes' �Jacke+�x�v . > ► <br /> Wtd wr:,4- be aPPI' ' <br /> Z)Al l Ea L CU4_- � 6 ,�t-be-. 4mk+A oj-25p1l l iq <br />