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- ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION MR .AGROUND TANK RETROFIT, OR PIPING REPAIR PEI.._ <br /> THIS PERMIT EKPIRES 90 DAYS FROM THE APPROVAL DATE. GO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> TANK RETROPIT _ PIPING REPAIR <br /> - <br /> EPA SITE Y 1 PROSECT CONTACT 6 TELEPHONE #Mlyc33 <br /> FACILITY NAME �9--� <br /> CADORXSS llh f���fff� 1 1 F STOC �� <br /> _ CROSS STREET I <br /> O E DERATOA �� ���� PHONE 11 C <br /> TRA <br /> C CONCTOR NAME JT'Ya+-� C¢� �r PHONE Ylt//VV� _ I7333 <br /> O , •. • e HCl <br /> !1 I CONTRACTOR ADDRESS <br /> R INSURER Q ` � + ' r^ `• ��//�\�1 •v c� YORK.COMP.1� 6 - 6 <br /> COTHER INFORMATION c d <br /> T <br /> O I I PHONE Y I <br /> R <br /> PHONE E <br /> TANK <br /> IIIIIIIilll11111111111111 <br /> TANK ID Y E C ZCALS STOR¢p ENTLY/PREVIOVSLY OATS UST INSTALLED <br /> I9- I <br /> 39- o I� oC-1 I 1 <br /> N 39- <br /> K 29- <br /> 19- I <br /> I I1TfTTTT(iTTTTTiiTTiTfiil111Ti I I I111i 111 fTTTi71111171 i i i ITM <br /> v <br /> APPROVED APPROVED WITH CONDITION(S) DISAPP0.0VE0 I <br /> (SEE ATTACHMENT WITH CONDITIONS( <br /> N PLAN REVIEWER$ NAME DATE <br /> IIIIIIIIIIIIIIIim i"TnTnTnTuTuTiIIIIII 11111111111111111111111111111 IIIIIJITUMIIIIII I IIIIIIIIiI <br /> PLICANT MUST PERFORM ALL YORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC E YW SERVICES. Oi R OR'LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN <br /> TF.Y PERFORMANCE OF THE YORK FOR WHICH THIS PE IT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A HANKER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALS 0 IIA.•' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWINC:I <br /> I CERTIFY THAT IN THE PERFOE-YO THIS PERMIT IS ISSUED, I SL EMPLOY PERSONS SUBJECT TO WORKER'$ <br /> CDMPENSATION LAWS OP CALIFORNI <br /> APPLICANT'S SIGNATUR - TITLE-:jV VVV-)&F(-/L DATE <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyon2 <br /> permit payment coverage per tank. If the party designated below is different than the permi� <br /> applicant, e.g. property owner, the party must acknowledge this responsibility for the billinc_ <br /> by signature and date below. 'JI tj" <br /> Name f �P�C Y f7r� / address 21"�Gr p44o e number / n x-01 67 `4 6 --q-W <br /> Signature <br /> 7-H 23-0038 <br /> 1 <br />