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. ENVIRONMENTAL HEALTH DIVISION - • " <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, 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 REPAIR/RETROFIT -_TAXK LINING _ <br /> NAME f <br /> PIPING REPAIR <br /> EPA SITE PROJECT CONTACT & TELEPHONE Y �v <br /> F FACILITY Nj ' <br /> C ADDRESS 7I <br /> I 1 �1 <br /> L CROSS STREET <br /> I <br /> I OWNER/OPERATOR <br /> T PHONE 9 <br /> C CONTRACTOR NAME <br /> 3ve-�lia5 i <br /> O �e• PHONE 3 <br /> N CONTRACTOR ADDRESS <br /> T CA LIC S <br /> R INSURER a76 CLASS <br />� D y�� <br /> A I WCRK.CCMP.',t f7 <br /> C OTHER INFORMATION <br /> T <br /> l I PHONE Y <br /> ►Illlilllllllllliillilllllllll PxDNE s <br /> TANK IO 2 TANK SIZE <br /> 39- CHEMl GALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> 39- ----- <br /> 39- <br /> 39- <br /> ----39-39- <br /> 39- <br /> 39- <br /> 1111 ----._ <br /> _ APPROVES APPR VED VI CONDITIONS) <br /> PLAN REVIEWERS NAME <br /> ( Ec TH CONDITIONS) <br /> —' DISAPPROVED <br /> 1lillllll111111111111 11111lI1111111 1111DATE <br /> 111 11111 11111111111111111111 11 111111111111111111111111111117111111111111 <br /> :PPLICANT MUST PERFORM ALL WORK IN AC ANCZ WITH SAN JOADUIN COUNTY <br /> 'AN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSE*). AGENTS SIGAA7URESC&TTIFEES THELOWlNGiDIREGUI.A7I0H5 OF <br /> HE PERFORMANCE OF THE WORK FOR WHIC9 ANIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER CERTIFY <br /> TIHECTt ET IN <br /> UBJECT i0 VORKER•S COMPENSATION LAWS OF CALIFORNIA.- CONTRACT p�nr.w� <br /> L CERTIFY THAT IN THE PERFORMANCE OF THECR'S HIRING OR SUBCONTRACTING SIGNATURE CE.TTFIES THE FOLLOWING: <br /> CMPENSATI6V LAWS OF CALIFOR WORK FOR WHICH THIS PERMIT [S ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> PPLICANT'S SIGNATURE: Wj�/����/� <br /> V /�// / TITLE A/ <br /> C� <br /> [NG INFORMATION: <br /> :are the responsible party to be billed for additional PHS-cH0 staff time expended <br /> • designated below is different than the beyond perait payment coverage per tank. If the <br /> �i(li n9 by signature and date be ow_ permit appliwnr, e_g_ property ower, the parry must acknowledge this responsibi[iry for <br /> Ing Addr <br /> loner. ) _ <br /> cur <br /> 0121 0 <br /> IIC <br /> 0038 _ p hVWVi' ✓ r I SCG L/yllX. �r I , F�- �J� -tom YV/1�. <br /> IYL <br /> 1 <br />