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1-09-1997 9:64AM FROM P. 3 <br /> ENVIRONMENTAL HEALTH oIVIsION <br /> APPLICATION FOR Ulloej OUND TANK RETROFIT, TANK LINING, OR PIPING Az�_[R PERMIT <br /> :NIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANT SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> TANK REPAIR/RETROFIT „TANK LINING PIPING REPAIR <br /> EPA SITE 0 PROJECT CONTACT L TELEPHONE 0 F MV _4a <br /> F FACILITY NAME <br /> A C-1 PRONE JJ <br /> 7 "1 <br /> AOORESS <br /> I 1 <br /> Pte. <br /> L CROSS STREET v <br /> P IF <br /> T OWNER/OPERATOR TH E C Lk C L E K, t)VIA P IA NY PHONE 0 <br /> T ►� DIvIS G{- GORPOh1►411 aD(o -�i �l�-�3� <br /> L CONTRACTOR NAME ��\ N v t_'C T—i^IU II�IJ� 1ti N_r L- PRONE C <br /> 0 v g 1 Tal, <br /> N CONTRACTOR ADDRESS , W� E CA LIC 0 CLASS <br /> T <br /> R INSURER MATRIC.CONP.O <br /> A <br /> C OTHER INFORMATION <br /> I <br /> 0 PHONE 0 <br /> R <br /> PHONE 0 <br /> 111111111111111111111111111111 <br /> 39- <br /> TANK 10 0 TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> Y 39- <br /> A 39- <br /> N 39• <br /> t 39- <br /> 39- <br /> 39- <br /> 1111 <br /> P <br /> L P _ APPROVED WITH COW ITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) T <br /> N PLAN REVIETIERS NAME- DATE n L <br /> IIIIIIIIIIIIIIIIIItI I II 11 I 11 111111 111 11 II 111111 IIII I <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 /> TME 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.- COUTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> O CERTIFY THAT IN THE PERFNCE OF THE K fOR NMICN TNfS yERHiT Is ISSUED. I sxAll EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF FO N[A. 1 _.viJ.�—llYi///�_� <br /> I <br /> 741L_) <br /> APPLICANT'S SIGNAT TITLE (_L'l'Nfil )WF. ,_'�PE!^ DATE 4442 <br /> G <br /> RfLLING INFORMATION: <br /> indicate the responsible party to be billed for additforml PNS-EHO staff time CAPended beyond permit payment coverage per tank. If the <br /> Party designated below is different than the permit eppticant, e.g. Property Owner, the party oast acknowledge this responsibility for <br /> the billing by signature and date below. <br /> ' <br /> 1 '1 {'V� SryL li-u I H� � La l= K rjrnAf1-r`i^VV�����11t-t 1 IV LSIM ntn <br /> i- I c;� <br /> Meiling Address 69(71 0 U AI I -'D-UL v9� JEATT"1_c— A q)�� 10L <br /> Day Phone Number C 20 C- ) Ll 11 �— �- 'z, <br /> Signature <br /> RM Z3-0038 <br /> 1 <br />