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ENVIRONMEV::.L HEALTH DIVISION <br /> 1 APPLICATION FOR UNDERGRTANK RETROFIT, OR PI?ING REPAIR PERMIT <br /> THIS PSRMIT EXPIRES 90 DAYS FROM THE APPR DATE. DO HOT WRITE IN ANY SHADED AREAS. <br /> CATE PERMIT TYPE BELOW: <br /> TANK RETROFIT PIPING REPAIR <br /> EPA SITE # PROJECT CCNTACT S TELEPHONE <br /> FACILITY NAME 1 ` /`\ ��t J�,.�L(�� A �� ?HONE $ <br /> A / <br /> C I ADDRESS `� I v{'i� �"-N C.I -> C.zA13C } G'T F;CACZiC11 <br /> L � CROSS STREET ,7 1 <br /> "' OWN' TO PHONE p <br /> C CONTRACTOR NAMEC PHONE A�Oq-c/bN <br /> N CONTRACTOR ADDRESS - C. 10 `>T� -CA LIC #'3&OL`���ICE <br /> CLASS.�!• / <br /> R I INSURER _ .4 � WORK.COMP. l._.L"l•��' Z' Y--� <br /> A <br /> ^_ OTHER INFORMATION <br /> D PHONE 11 <br /> R P40NE # <br /> IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII <br /> TANK ID R TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DA^ UST INSTALLED <br /> 39- L4.,OODrA(-2CJ`> 1 U1•�tF�{Y� <br /> T I 39- GA:!.i i <br /> A 1 39- <br /> N 1 39- <br /> X 1 39- <br /> 39- <br /> -9- <br /> �II t <br /> 111111111111111111111 II III I IlllllllllilllllllllllPP VED APP C'._] WITH CCNDITICNISI DISAPPROVED <br /> lS TTAC:C BNT KITH CONDITIONS) <br /> N 1 ?LAN REVIEWERS NAMEDATE <br /> TI 11111111111111111111111111111111111111111111111111111111111111111 1111111111111111 11111111111 <br /> APoLICANT :MUST PERFORM ALL 'FORK IN ACCORDANCE WITH SAN JCAQU-N COUNT" ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF I <br /> SAN JOAQUIN COUNT- PUBLIC HEALTH BE 5. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN j <br /> -HE PERFORMANCE C THE WORK FOR WHICH IS PERMIT :S T-SSL3D, : SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS .0 BECOME <br /> SUBJECT TO WORKER'S CCMPENSAT FORMA." COV:RACTOR IS HIRING OR SUBCONTRACT ING SIGNATURE CERTIFIES THE FOLLOWING: <br /> CERTIFY ':HAT :N THE E FO E OF HE 80AK i0 ICH -'HIS PERMIT :S ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WCAKEA'S j <br /> =1PENSAT:ON LAWS OF C I IA. <br /> APPLICANT'S SIGMA:URE: <br /> - TITi 1Y��� IFQ'�_ DAT= <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time e:roended 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 r ss phone number1 y� —-s(I _ <br /> Signatur � - <br /> / CY rr� rvX� e 0 PAS <br /> EH 23-0038 <br /> w l ve - <br /> rrJ <br /> 1 <br />