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' APPLICATION FOR UNOEAOND TANK RETROFIT, TANK LINING, OR PIPING &R PERMIT <br />TTS 3f-* IT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />\ _TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br />EPA SITE I PROJECT CONTACT & TELEPHONE <br />A FACILITY NAME I PHONE S7 Q <br />I ADDRESS <br />L CROSS STREET S" <br />I <br />T OWNER/OPERATORI PHONE 9 <br />Y e�o 7 - 9s_1? - oS 7 <br />C I CONTRAC70R NAME I PHONE <br />0 <br />N CONTRACTOR ADORESS „ 1 CA LIC / /_ 00 ;76 I CLASS / <br />R i INSURER /3 /f Kms// IOCo WORK. L7 l: PtFX 3 843'1/ � ��9�0093q 98 <br />C I OTHER INFORMATION <br />7 <br />0 I PHONE <br />R <br />II IIIttllillllllilll U 111111111 � ?HONE <br />iii ID T TANK SIZE CHEM CALS STORED CUR��-NTLY/PREVICUSLY DATE UST INSTALLED <br />39- I lam' ' (1J ��7 I__T (� �1 <br />T 39- <br />A 39- <br />39- <br />39- <br />39- <br />I fil <br />9-39-39-39-Ilii ( ffi <br />L APPROVED APPROVED WITH CONDITICN(S) DISAPPROVED III <br />a EE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME GATE Z� <br />111111111111111111111111! 1111111111111111 1111111111111 11111lllllillll11i11 1111111111lIIIIi111lllil lill11t111111i11111111 <br />APPLICANT MUST PERFORM ALL WORK IN AC=RDANCE 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 <br />IN SUCH A MANNER AS TO 3ECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CON7RAC7CR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT 70 WCRKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />'17 <br />APPLICANT'S SIGNATURE:V TITLE PiDATE <br />13ILLING INFORMATION: <br />indicate the resoonsibte party to be billed for additional PHS -END staff time expended beyond permit payment coverage per tank. If the <br />party designated below is different than the permit appticant, e.g. property owner, the party must acknowtedge -.his responsibility for <br />the bitt'ing by signature and date below. <br />,Mailing address <br />Oay Phone Number ( ) <br />Signature EH 23-0038 <br />Pre-"� <br />i <br />