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08/03/2001 14:49 2094683433 FIFTH FLOOR PAGE 02 <br /> EMRROHIKENTAL B n7H DIVISION " <br /> APPLICATION POA UNDER/3ROUN0 TANA RETROFIT, OR PIPING REPAIR PERMIT <br /> TRIS PERMIT EXPIRES 90 DAYS FRAM TSS APPROVAL DATE. Do NOT WRITE IN ANY SNAP= AREA5. =KATE PERMIT TYPE EELOW: <br /> TANK RETROFIT 4 <br /> PIPING REPAIR <br /> EPA SITE # PROSECT 6MMACT 6 TEf.ELHONE W <br /> PRONE 'v a _ <br /> F FACILITY NAME W <br /> A 1 <br /> C ADDRESS <br /> L I CWDSS STREET - <br /> 'IT OWNER/DPERRTOA 980NE # <br /> Y C��1'S� mv\n pcC9-\,Z- 2uS- b ^ <br /> C CONTRACTOR NAME PRONE # _ 9 <br /> 0 I CR LIC # / /.� I CLABS <br /> M I CONTRACTOR AODRES3 <br /> R I IN30RBR I WORK-COMP.# <br /> • I I <br /> C I OTHER SRFORNATIOM <br /> T - <br /> O <br /> B � PNGNE M I <br /> —�Illllllllll,l NKII)I) ylillllillll' SIZE [SIC ST,"p CLRRENTLY/PREVYOVSLY VACu UST IRs AL= <br /> T j39. <br /> 39- I I <br /> NJ 39- <br /> KI <br /> 9-KI 39- I I <br /> 1 J9- <br /> 1 J9- <br /> �ununw unw nnul nunu nnn 1 uunl ulliu Haul ulna unn nllu inns Ina uul� <br /> APPROVRD WITS ComnmON(S) DISAPPROVED �y <br /> Ai (SEE ATTACHMENT WITY CONDITIONS) `I V <br /> �N PLAN AEVIEWERS <br /> IIIIIIttnIt1111tII t 1 I 1 1111111 111111 1111 1111111 Illtlltllllil TIIIIIIII11111II111111� <br /> APPLICANT MUST PERFORM ALL WORK IN AC W BAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES ANO REOUL.TIONS OF <br /> SAN JO =K COUNTY PUBLIC HSALTS SERVICES. OMNAA OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: -I MTIFY TWAT IN <br /> :'AE PERFORMANCE OP TSE WORK FOR WHICA THIS PERMIT I5 I55UED, I SuN..r. NOT Ee1PLOY RNY P81150N IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S CONDENSATION z WS OF CALIFORNIA." CONTRACTOR'S SIAM OR SOaCONITiACTING SIGWATDRE CERTIFIES TKE FOLLOWIMG:I <br /> 'I CERTIFY TRAT IN TSE P&RFORMANCE OF THP WORK FOR <br /> WHICH ISIS PERMIT IS ISSUER, I SNALL EMPLOY PERSONS SUBJECT To WORKER'S <br /> COMFENSATION LAWS OF CALIFORNIA.' <br /> APPLICANT'S SIGNATURE: Al,, Il T:L- TITLE CYC\' - SacQ A, <br /> O ppTS <br /> BILLING INFORMATION: / <br /> Indicate the responsible party to be billed for additional PHS-SBD 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. ( " 9 Slia <br /> Name b �1" ""address I O 1 1Phone number. <br /> Signature X' el , <br /> BIT 23-0038 <br /> rz- <br /> �. (U\VE <br /> 1 ' <br />