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• APPLICATION FCR UNDE1 !NJ TANK RETROFIT, OR PIPING REPAIR PERMIT <br /> :'HIS PERMIT EXPIRES 90 DAYS FRGM THE APPROV;,:. DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT PIPING REPAIR <br /> EPA SITE # PROJECT CONTACT & TELEPHCNE # �n <br /> r I ?AGILITY NAME PHONE #. �./ <br /> A <br /> ADDRESS ' v l�-� <br /> I <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE <br /> I-P �"'t 6 b - 1 17 <br /> C I CONTRACTOR NAME PHONE # (j) <br /> 0 -/I .JJ <br /> N CONTRACTOR ADDRESS /�� 1,1./ I CA LIC # CLASSAc-1 0 <br /> 2. <br /> RINSURER I WORK.COMP.#� <br /> A <br /> C OTHER INFORMATION <br /> T <br /> 0 I ( PHONE # <br /> R <br /> PHONE # <br /> -1111tlillllllllillllllllllllllll <br /> TANK ID # TAIN- SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY7DATE UST INSTALLED <br /> 1 39- 1 <br /> T I 39- 1 I <br /> A t 39- 1 <br /> N i 39- 1 I <br /> K I 39- 1 <br /> 1 39- 1 <br /> l 39- 1 <br /> --1iiII1111111111111111111111II111111111111iIi1llI11111111111111111illllilllllil1111111111111II1111111111111111111111111111111111 <br /> APPROVED �/ APPROVED WITH CONDITION(S)-'� DISAPPROVED 1 <br /> A (SEE ATTACHMENT WITH CONDITIONS) ' 1 <br /> N l PLAN REVIEWERS NJ DATE V- <br /> -Illlillllllillltllll�lll-1 1111111 Illrill 1 llllillllllllllllllllllllllllllllilllllilllllllllll it Illllllllllllllllllilll <br /> APPLICANT MUST PERFORM ALL WORK IN ACCCRDA'CF_ ni.H SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEAL--H SERVICES. O�ti-R OR LICENSED AGENT'S SIGNATJRE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN j <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 COMPENS TIO,' LAWS OF CAL:=CRNIA.• CONTRACTOR'S HIR'--NG OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING-.1I CERTIFY THAT IN THE PER 0 'VCE OF THE WORX FOR WHICH THIS PERMIT IS ISSUED, I L EMPLOY PERSONS SUBJECT TO WORKER'S I <br /> COMPENSATION LAWS OF CAL I O IA.• 7 <br /> APPLICANT'S SIGNATURE: TITLE ATE <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, e.g. property owner, the party must acknowledge this responsibility for the billing <br /> by si ture nd date below. <br /> N a d s s ( ►1 done number 2,09 - <br /> Signature L-1 <br /> EH 23-0038 <br /> 1 <br />