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APPLICATION FOR MOESANK RETROFIT,' OR PIPING REPAIR PERMIT• <br /> THIS PERMIT EXPIRES 90 DAYS FROM Tf2;' APPROV; DATE. DO NOT WRIT£ IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> TANK R-:aOFIS _ PIPING REPAIR <br /> j—D9 <br /> EPA SITE q PROJECT CONTACT b TELEPHONE q ' �`.��' <br /> FACILITY NAME PHONE p O 7 <br /> A 1 C <br /> c I ADDRESS <br /> I <br /> L I moss STREET i <br /> I /a N^ <br /> T <br /> ' OWNER/OPERATOR q'I/ W i PHONE <br /> i <br /> C CONTRACTOR NAME <br /> N' I CONTRACTOR ADDRESS �� I CA LIC % ' /107 I CLASS l0 NAz <br /> !�- <br /> R I INSURERI WORX. MP. <br /> A u <br /> C I QSHER INFORMATION <br /> T <br /> O I I PHONE p 1 <br /> R I I ) <br /> PHONE 3 <br /> - ji111111111111111111111111111fi1i <br /> TANK ID p TAVeCALS: SIZE CHEHZSTORED CURRENTLY/PREVIOVSL'f DATE VST INSTALLED <br /> 1 39- 1 I ( I <br /> T I 39- <br /> A I 39- I I I <br /> N 1 39- i <br /> K I 39-- <br /> 39- <br /> 39-_ <br /> 9-39- J I I <br /> —�IIII IIII Hill III 111111111111IIIIIIIf11111111111111111f111111111111111111111V�T1[T1�111f1lllfllllllllfllllllllillllllllllllllilllllll <br /> L 1 APPROVED APPROVED WITH CORDITION(S)" DISAPPROVED <br /> A I (SEE ATTACHMENT WITH CONDITIONS) a 1 <br /> N I PLAN REVIEWERS NAME DATE W) JCI <br /> - Illlllllllllllflllllfl .1 11111 1 1 III111111IIIIIIIIIIIf111111111111111111111I1111 II II 11111111111111111111 <br /> I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCCRpA^ E - II 5 p JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. ,..mR OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY TRAT IN <br /> SHE PERFORMANCE OF TAE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME. <br /> SUBJECT TO NORKER'S COMPENBA N LAWS OF GLI_ORNIA.• CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLONING:j <br /> •Z CERTIFY THAT IN THE PERE VCE OF THE WORK FOR CH THIS PERMIT IS ISSUED,LLMPLOY PERSONS SUBJECT TO WORKER'S <br /> CDMPINSATSON LAMS OF CAL �APPLICANT'S SiGHATVRE: SZSL ��Y,//IIAAJJ AA�'J'Jff/yyEE//�c// <br /> BILLING INFORMATION: <br /> - <br /> Indicate the responsible party to be billed for additional PHS-EHD 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. <br /> Name/ �ess 'f/ hone numbe �_��!// �� <br /> Signature <br /> EH 23-0038 <br /> OF vzzuo <br /> 1 <br />