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" ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERG AD TANK RETROFIT, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE :N ANY SHADED AREAS. INDICATE PERMIT --.'PE 3ELOW: <br /> _TANK RETROFIT L PIPING REPAIR <br /> 'c PA SITE X C A� PROJECT CONTACT 6 TELEPHONE + c►�1 <br /> FACILITY NAME PHONE20 YS 9S?-�3 /O <br /> A V_w /� C <br /> C I ADDRESS 7 7NA x/)16 aEC.A^jy C i V�d L-�T� N <br /> L CROSS STREET <br /> T OWNER/OPERATOR ^ f� ^L/1 /CPHONE <br /> C oCi ?HONE " <br /> ONTRACTOR NAME GG 5EeV�cEJ l`�cC) Gr T T (f 1 7 3 0 <br /> N 1 CONTRACTOR ADDRESS CA If 9 7o4, Cd f Z I CL SS <br /> R I INSURER �'��'�� �J/\/� I WORK.COMP. <br /> A <br /> C OTHER INFORMATION <br /> PHONE # <br /> 0 <br /> R <br /> PHONE <br /> �IIIIIIIIIIIIIIIIIIIIIIIIIIIIIII <br /> TANK :D # TANK SIZE I CHEMICALS STORED CUR-RENTLY/PREVIOUSLY I DATE UST ZNS'+:LED <br /> i 39- <br /> 7 I 39-- <br /> A <br /> 9-A 1 39- <br /> N I 39- <br /> ti l 39- <br /> 1 39- <br /> 1�11CPIT <br /> cAPP�{OVED APPROVED WITH COT (S) DISAPPROVED <br /> T 1 o SEE A . HMENT WITH CONDITIONS) DAT_ <br /> N 1 PLAN REVIEWERS NAME E <br /> ----II11111111111111111111�1111111111111111 11111111111111 Illilllllilillllllllllillllllllilllllllllllllillilllilllll <br /> TP?LICASIT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQU:N COU:7TY ORDINANCES, STATE LAWS, AND RULES A.`rJ REGULATIONS O. <br /> STN JOAQUIN COUNTY PUB L:C HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY TF-+- ZN <br /> THE PERFORMANCE OF THE 'WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A :4ANNER AS TO BECOME <br /> SUBJECT TO WCRKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:I <br /> "I CERTIFY! :HAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CAL:FORNIA. / ,/ <br /> APPLICANT'S SIGNATURE <br /> „�(,� �'�/�--� TITLE 5'721/. Lf �EC.-�' DATE 7 <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 signature and date below. Yres�,e ��., g37?1V <br /> Name% — address _sZ7N-�i4rV< P <br /> _phone number <br /> � 1 ` <br /> 4lF�rv� <br /> Signature <br /> EH 23-0038 <br /> 1 <br />