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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERG2CUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPI2ES 90 DAYS FROM THE APPROVAL DATE_ DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _TANK REPAIR/RETROFIT TANK LINING PI ING REPAIR <br /> _� r <br /> EPA SITE R PROJECT CONTACT & TELEPHONE 3 C <br /> F FACILITY NAME PHONE X <br /> A <br /> C ADDRESS l <br /> I <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR <br /> Y PHONE Y <br /> C CONTRACTOR NAME <br /> O <br /> i CONTRACTOR ADDRESS r U LTC 3 W/ �1I lI.11LL L.C/ t/d <br /> 2 INSURER W /7'JZ <br /> M WORK_COMP-u. !mq pi <br /> OTHER INFORMATION ( UUV O <br /> I <br /> t I PHONE <br /> 222222222222222222222222222222 I PHONE 3 <br /> 39- <br /> LANK TO at, TANK SIZE CHEMICALS STORED CURRENTLY/PREVIGUSLY DATE UST INSTALLED <br /> 39- <br /> 39- �— <br /> 39- �— <br /> 39- —�— <br /> 39- <br /> 39- _ <br /> 2222 <br /> APPROVED APPROVED WITH CCNDITICNCS) _ DISAPPROVED <br /> F�'-�--1- - ATTACHMENT WITH CONDITIONS) <br /> PLAN REVIEWERS NAME (�{/I.(� A` Q alaDATE / a-� Q r <br /> 211121(illllillllllililllil"lnuuluu�l uulul <br /> I lFI I I I I I I 1 11111 11111 1111111llluluuun <br /> PPLIUNT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAH JCAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> AN JCAOUiN COUNTY PUBLIC HEALTH SERVICES_ OWNER OR LICZNSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING,- •I CERTIFY THAT IN <br /> HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> JB:ECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA-' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> I CERTIFY THAT IN THE PERF CE OFFTTHE WORK FOR WHICH THIS PERMIT IS ISSUED, t SHALL EMPLOY PERSONS SUBJECT TO 'JCRI.ER'S <br /> CMPENSATIGV CAWS CF ULIFO NI _ <br /> Y C G 'fir / <br /> 'PLICANT'S SIGNATURE: TITLEgG _'��' <br /> Ll�l/ <br /> NG INFORMATION: <br /> are the responsible party to be bitted for additional PNS-EMD staff time expended beyond permit payment coverage per tank_ If the <br /> designated beton is different than the permit applicant, a-g_ property owner, Ghe party mzs: aclmfllenc a this rpert tank- <br /> itf far <br /> it Cing by Si cure date bel - n <br /> tg Address �y <br /> tone Nunbe ) T. <br /> Do3a ✓ ,adu� rit.#__ -4-a <br />