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7�'6—i yz7b i :uJF ai Rui <br /> ENVIRONMENTAL HEALrN DIVISION <br /> .APPLICATION FOR UNOE"GROW NK RETROFIT, TANK LINING, OR PIPING REPAIR D, .T <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. ,DLO NOT WRITE IN ANY S94ED AREAS. INDICATE D£RMIT TYPE BELOW: <br /> TANK REPAIR/RE7R0fiT TANK LINING PIPING REPAIR <br /> EPA SITE Y w PROJECT CONTACT L TELEPHONE R ' (, <br /> A <br /> FACILITY NAME = PNONE 1t ( C <br /> C ADDRESS - _` <br /> I 1 <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PSE _ <br /> Y - <br /> C w UL <br /> C CONT" CTOR NAME ` S C PNCNE s <br /> 0 <br /> N CONTRACTOR ADDRESS _ CA LICit ^ I CLASS ��I <br /> R INSURER _ WORK.C@rP.1 9'7 5ci X111 <br /> A <br /> C OTHER INFORMATION <br /> T I <br /> 0 PHONE Y <br /> t <br /> PHONE x <br /> Itlltf l!!lllltltltlll11il1llil <br /> rANK IO x TANK SIZE CHEMICALS STORED CURRENTLY/PREVICUSLY DATE UST INSTALLED <br /> �9- <br /> r 39 may. �_ k <br /> A 39- <br /> N 39- <br /> 39- <br /> 39- <br /> 39- <br /> L <br /> 9-39- <br /> 39- <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTAC,NMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAMEDATE <br /> Illlllll11lt1tiltlll ilt tit111111111111111,11, <br /> 1 t IlIffn1=11 11111[t <br /> tiiiiiiiiiiiiiiiiiiiiiiiiiiiifillilI <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOA IN C0LMTY ORDINANCES, STATE LAYS, AND RULES AND RE WLATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICwNSBD AGEAT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE P-ERFORMANCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO 4ECCRE <br /> SU84ECT TO WORKER'S COMPENSATION LAWS Of CALIFORNIA." CONTRACTOR'S HIRING OR AIBC=TRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "! CERTIFY 'NAT IN THE PERFORMANCE Of THE WORK FOR WMICB THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." — — <br /> APPLICANT'S SIGNATURE: V �, ��� Lt /�, TITLE � �. PATE V <br /> �LLING INFORMATION: <br /> -3dicate the responsible party to be billed for additional PIIS-EHD staff time expel beyond permit payment coverage per tank. If the <br /> Irty designated below is different than the permit app(icant, e.g. properly owner, the party must acknowledge this responsibiLiry for <br /> ie biLLinq by signature and date below. <br /> filing Address <br /> ,y Phone NUiber ( ) <br /> gnsture <br /> i3-Doss <br /> 1 <br />