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....- I, . ...-- <br /> APPLICATION FOR UNn'�GRCUNO TANK RETROFIT, TANK LINING, OR PIPIPI PEPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THL APPROVAL DATE. DO NOT WRITE IN ANY SHADED A,, AS. INDICATE PERMIT TYPE BELOW: <br /> _TANK REPAIR/RETROFIT _TANK LIMING _ PIPING REPAIR <br /> EPA SITE 9 I PROJECT CONTACT L TELEPHONE 9 ` �- 3;ec <br /> FFACILITY NAME PHONE )c J cJ <br /> A I <br /> C ADDRESS - <br /> I4Y11-2z) Ci cJ/f !� <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE <br /> C CONTRACTOR NAME G e /> �� PHONE " ' <br /> 0 G� f <br /> N CONTRACTOR ADORES r CA LIC A In C 769 I CLASSA 'U <br /> T v /i '! <br /> R I INSURER (� WORK.COMP.: O�� /pr',l�- / <br /> v LIU) <br /> L0C <br /> OTHER INFORMATION <br /> IPHONE ;9 <br /> PHONE S <br /> 1111111I1111(i]lI11111I1111111 <br /> 39- <br /> TANK 10 T TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED <br /> T 39- I <br /> f <br /> A 39- I <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P 1111 <br /> L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A SEE ATTA WIT CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> I1111(1111(11111111111l1 illlillll] 1111 !!11111 1 1!I 11111111111111!!1111 11 1111111II11111l1111111i11111lI111iIil11lll <br /> APPLICANT MUST PERFORM ALL WORK, IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUIN 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 PE. NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED I SHALL EMPLOY PERSONS SUBJECT TO WCRKER'S <br /> CCMPENSA7ION LAWS OF CA FORK A." <br /> (M <br /> ,� q2 <br /> APPLICANT'S SIGNATURE. TITLE DATE <br /> BILLING INFORMATION: <br /> Indicate,' e responsible party to be billed for additional PHS-END staff time expended beyond permit payment coverage per tank. If the <br /> party ' sig aced below is different than the permit applicant, e.g. pr�rty owner, the party must acknowledge this responsibility for <br /> the b ll'in by signature an ate below. <br /> Name LCL! <br /> Mailing A s / . <br /> Day Phne N r�) ( / <br /> Signal <br /> DOS '. <br /> EH 23-0038 I\ ( — — LW O^ . <br /> 2)A�I,� P��--�►��-�- I�vlod-��.�G� E'vu-cif G-� �t�--e (,��pv�r�. <br />