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ENV IK-11----&- fir NLIII utVI�jCN <br /> APPLICATION FOR UND( 'JNO TANK RETROFIT, TANK LINING, OR PIPING IR PERMIT <br /> THIS CERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> —kTANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br /> EPA SITE x PROJECT CONTACT b TELEPHONE tt `CCtt <br /> A FACILITY NAME PHONE <br /> ADDRESS <br /> I a� a- V,), <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR \ I PHONE Al <br /> Y . t V c� :—O C-"U\\ a t,C\ <br /> C CONTRACTOR NAME � PHONE X <br /> 0 <br /> H CONTRACTOR ADDRESS ,1 l CA LIC \qJ�y CLASS f" - (--)V--lZ. <br /> 7 <br /> R INSURERAc^QC WORK.CCMP. � BG�1 G`Cl OS <br /> A �Lta... G1 <br /> C OTHER INFORMATION <br /> T (�s-RC2 <br /> 0 \C ` ,\Z C> \ PHONE <br /> PHONE <br /> 111111111111 f 11111111111111111 <br /> TANK ID 4 TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> T 39- 2 LF . <br /> A 39- \ .*-e <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P 1111 <br /> L APPROVED APPROVED WITH CONDITICN(S) DISAPPROVED <br /> A (S TTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME (� �c DATE <br /> IllI11111111II111111111�I1111I IIIIIIIII III11 111111 1-fl 1I itITIITIII IIIII IT�ITI1l111 11 111111 111111 1IIIIIIIIl1I <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: <br /> "I CERTIFY THAT IN THE P CE OF THE�WORKF �THISPERMIT IS ISSUED, I SHALLEMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF LIFORNIA." <br /> APPLICANT'S SIGNATURE: L TITLEc�ncL�C G DATE <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PNS-EHD 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 Cbelow. <br /> Name F,,2-(_0 3--a�.1 AL.�S L" i <br /> Mailing Address Lad�tC v�� r_ \.G� ?i,AW'.CA C.C, <br /> a <br /> 7Vt Law <br /> C <br /> A ed <br /> �( t C <br />