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ENVlnUwiu4lnL nuALlll UIVISION <br /> APPLICATION FOR Uy�¢GROUND TANK RETROFIT, TANK LINING, OR PIP EPAIR PERMIT 1 <br /> THIS PERMIT EXPIRES 90 DAYS FROM TI.� APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _TANK REPAIR/RETROFIT _TANK LINING A_ PIPING REPAIR <br /> EPA SITE # PROJECT CONTACT & TELEPHONE7 <br /> \_ rnAs-�5 4 <br /> F FACILITY NAME C\ `Q.4 # HONE # <br /> A I <br /> C ADDRESS 9 <br /> I — <br /> L CROSS STREET <br /> I <br /> I OWNER/OPERATOR (� r —t^ \- PHONE # <br /> Y W S�UM.Q1� T70 - -L S— <br /> C CONTRACTOR NAME ; PHONE it <br /> O 5 71 <br /> N CONTRACTOR ADDRESS 25.33 CA LIC # CLASS` I <br /> I <br /> 5C)23-77 - <br /> R INSURER q �7 pp <br /> A WORK.COMP.# P� J QCb 1-r l <br /> C OTHER INFORMATION <br /> T <br /> 0 <br /> R PHONE # <br /> PHONE # <br /> TANK ID # <br /> 39- TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> T 39- + ik I?Cas U ml\a Acs CASoI a _v:J`F_. <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P "11'111'111111111 <br /> L APPROVED APPROVED WITH CONDITION(5) _ DISAPPROVED <br /> A p(¢�E ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME.7� DATE �— <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 THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFO I <br /> APPLICANT-5 SIGNATURE. TITLE DATE b <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-END 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 responsibility for <br /> the bitting by signature and date below. <br /> Name <br /> Mailing Address ? e �kc-LUQ— <br /> �c��arn2NCl7 l C.� GSA\S <br />