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:NVln..uu"..,.L ncnLlu Jl/l�iC4 <br /> APPLICATION FOR LINDE 'NO TANK RETROFIT, TANK LINING, OR PIPING 'R PERMIT <br /> THIS "ERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> TANK REPAIR/RETROFIT _TANK LINING _ PIPING REPAIR <br /> EPA SITE = PROJECT CONTACT b TELEPHCNE 3 <br /> FACILITY NAME R, C PHONE <br /> ADDRESS �`a-1 a- lv• �-��\� c\•�c� <br /> L CROSS STREET <br /> T OWNER/OPERATOR PHONE <br /> c � \ i<C� I <br /> C CONTRACTOR NAME T / I PHONE <br /> O l_ <br /> N i CONTRACTOR ADDRESS ( CA LIC CLASS <br /> R INSURER LC� WCRK.CCMP.»w 9$4ap% Cl`l OS <br /> A a <br /> OTHER INFORMATION <br /> T <br /> 0 C) \\ �� �`(\ PHONE <br /> PHONE ;f <br /> 111111111111)11111111111111111 <br /> TANK ID 4 TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> r <br /> 9 T 39- 2 <br /> A 39- : <br /> N 39- <br /> ( 39- <br /> 39- <br /> '9- <br /> 1111111111111111111111111111111111111111 <br /> \ <br /> L APPROVED �_ APPROVED WITH CCNDITiC4(S) DISAPPROVED <br /> A I(SErATTACHMENT WITH CCNDITiONS) S;J <br /> 4 PLAN REVIEWERS NAME DATE <br /> � 1111111111111111111lII1N11 111111111111111111 11111711111111111111111111 I lIIllTlilill 11111111111111111111lII111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JCACUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JCACUIN 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 ':ORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "! CERTIFY THAT IN THEFZ RK F �THISOF THE WOPERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WCRKER'S <br /> CCMPENSATION LAWS OF, LIF0RNIA." <br /> APPLICANT'S SIGNATURE: _ �� L �. TITLE 12\t:g \I�0.n�C`c�G DATE <br /> J <br /> 3ILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS--HD staff time expended beyond permit payment coverage per tank. If the <br /> party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br /> the billing by signature and date below. <br /> Name pa(—,o <br /> Mailing Address <br /> - Ct Q11 <br /> 'J � /{Lli�✓� Q�L.c�u -(3•�G�k. jam`` .�'`'T'�'>.c�< Clc,t•�:'f��� <br /> ,tib t <br />