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E-tIRUNP15NTAL HEA:,Ikl Ul'i:S10:7 <br /> APVLICJI bftERG1&JNd tANK RlTROIIT, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 I3AYgAt� NOT NRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> T X RETROFIT PIPING REPAIR <br /> EPA SITE I ^ PROJECT CONTACT i TELEPHONE OC eA7- <br /> F FACILITY NAME / ® iL J.eQI/ICS PHONE <br /> A O� <br /> ADDRESS I S 3/ a�{ .�Q I <br /> I <br /> L I CROSS STREET V <br /> I <br /> T OWNER/OPERATOR PHONE 0 <br /> Y <br /> C CONTRACTOR NAM .�_\ ! p <br /> PHONE p <br /> OCt Q <br /> N CONTRACTOR ADORES D 7r� CA LIC R `v r I CLASSC'd� //.+ <br /> T v ^ C1Tf L- <br /> R INSURER WORK.COMP.M go 161 7/ Z <br /> A v I <br /> COTHER INFORMATION i <br /> T <br /> 0 PHONE M <br /> R <br /> PHONE N <br /> TANK ID tf TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- I I I <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> I <br /> 39- <br /> I <br /> J9- <br /> �111� II I II1111111111111111111-1wI <br /> P <br /> L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) I <br /> N PLAN REVIEWERS NAME DATE <br /> (Iilllllllli mII mininninumn I 11111111111 11 11111iffffffuffIIIIII I IIIIIIIIIII111 11111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:I <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S I <br /> COMPENSATION LAWS OF CALIFORNIA.* i <br /> APPLICANT'S SIGNATURE: TITLE DATE <br /> BILLING INFORMATION: <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, 6.g. >property owner, the party must acknowledge this responsibility for the billing <br /> by signature and date below. <br /> Name address phone number <br /> Signature <br /> EH 23-0038 <br /> 1 <br />