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APPLIC4TION FSR UND -ANK RZTROFIT, OR PIPT_NG REPAIR PERMIT 10 <br /> THIS PERMIT EXPIRES 90 DAYS FRCM TPM APPROV:,J DATE. DO NOT WRITE IN ANYSHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> ,TAASX R-..OF IT _ PIPING REPAIR <br /> EPA SITE X PROJECT CONTACT 4 TELEPSCNE 9 <br /> FACILITY NA. <br /> PHONE p <br /> C I ADDRESS ° <br /> I / f <br /> I. I CROSS STREET . <br /> I <br /> T I OWNER/OPERATOR n <br /> PHONE 6 r/ <br /> C j CONTRACTOR NAME <br /> ®, <br /> O _ <br /> PHONE 3 <br /> CONTRACTOR D S I <br /> CA LIC 3 <br /> T i CLASSi..d. I <br /> R i INSURER 6f ✓✓ pip.,. , <br /> WORC.COMP_X .� X •���I <br /> A CJ G <br /> C I OTHER INFORMATION <br /> T I <br /> O <br /> I PHONE 4 I <br /> R , <br /> i PHONE 3 1 <br /> -- Illtiliiitifltitf6lltitlfii!!1[ = <br /> TANK ZD }) TAN:, SIZE CHEMICALS STORED CURRENTLY/PR 11 DATE UST INSTALLED <br /> I 39- t I 1 <br /> T I <br /> 39- <br /> 39- <br /> 39- <br /> 19- <br /> 39- <br /> 39- <br /> IM <br /> 161-—1-1-1 <br /> 9-39-39- <br /> 19-39- itttlfili111illltltlill(llilliil(lllttilttiltttlilli� <br /> APP. VED APPROVED WITH CONDI-=ON(S) DISAPPROVED I <br /> 1- C TTA WITH CONDITIONS) t <br /> -T t PLAN REVIEWERS NAME c DATE <br /> — <br /> lilllillilltliltllltifii 111 lit ft i t li Illillt IIIb!IIIIIIltiliitlllllllilltittllllt! I Itt! illil[Illllttilii <br /> APPLICANT MUST PERFORM ALL WORK ZN ACCCROAMC5 ::IT$ SAN SoAQUZN COUNTY ORDINANCES, STATE LAWS, AND .RULES AND REGULATIONS OF j <br /> SAM JOAQUIN COUNTY PUBLIC HEAL=S SERVICES. C-"7R OR LICENSED AGF.Nf•S SIGNATURE CERTIFIES THE FOL:.OWING: 'I CERTIFY THAT IN I <br /> :'S. PERFORMANCE OF THE WORK FOn :tFCICH THIS PERMIT IS ISSUED, Z SHALL NCT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME. <br /> SUBJECT TO WORK'-R'S COMPENSA O?N LAWS OF CAL:FORNTA CONTRACTOR'S HI2'_VG OR S CONT?2ACTZNG SIGNATURE CERTIFIES THE FOLLOWINC:1 <br /> ^Z CERTIFY THAI—. I:7 THE PER NCE OF -HE WG.2_: FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT "O WORKER'S <br /> L1 <br /> COMPENSATION AWS OF CALL ORNZ <br /> t <br /> APPLICANT'S SIGNATURE: ./ 1 <br /> TZ E4x&� DATE <br /> BILLING INFORNfATION: <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended bevond <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. <br /> Name — ress "phone number I <br /> S ignature <br /> EH 23-0038 C l <br /> 0�— a <br /> P� 4 <br /> r� <br /> 3 `� �� C� <br />