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r <br />APPLICATION FOR UNDEIW TANK RETROFIT, OR PIPING REPAIR PERMIT • <br />'.':IIS PERMIT EXPIRES 90 DAYS FRGM THE APPROV;,:- DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />TANK RET=OFIT PIPING REPAIR <br />EPA SITE X ' PROJECT CONTACT b TELEPHCNE K �� <br />F I 1rM '� PHONE # �� C; <br />A C <br />?AGILITY N <br />{ ADDRESS'C ' C) (. C ' Vf 1. { <br />I � <br />L ( CROSS STREET <br />I <br />T ( OWNER/OPERATOR �� /"�_ PHONE d I <br />C { CONTRACTOR NAME. PHONE # `L/ Ito ' <br />N { CONTRACTOR ADDR S r I/' ) { CA LIC i ( �( t�� ( CLASS /�. 6. I } { <br />T �f `�� / (�f (p� 7v� <br />R I INSURER Y � � WORK.COMP-x { <br />a <br />C { OTHER INFORMATION { { <br />T <br />0 I ( PHONE { <br />I <br />R { <br />( PHONE R { <br />-- <br />TANK 111[Iilitlttlllilllllllil <br />TANK ID p T:,Nc: SIZE CHEMICALS STORED CURRENTLY/ PREVIOUSLY DATE UST INSTALLED <br />1 39- 1 { <br />T I 39- 1 I I { <br />A I 39- <br />N t 39- { I I <br />K 1 39- { { <br />i 39- <br />--�111111111111t111l111111I111i11111111111111111111111111111t11111111111111111111111111111t1111!llllllillllillllllllllllillllill) <br />1 APPRO APPROVED WITH CONDITIONS) DISAPPROVED <br />A1 � ATTAC�9ENT WITH CONDITIONS)N PLAN REVIEWERS DATE 0'�- 1 <br />—111111111111illitlliilltll 1 11111 111111111111111illlllllllllllill111111111111111111iIIIIIIIIIIIIl 111 IIIIIIIIItllllllI <br />I <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />1 <br />SAN JOAQUIN COUNTY ?UBLIC HEALTH SERVICES. Cwti-R OR LICENSED AGENTS 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 IN SUCH A MANNER AS TO BECOME. <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.• CONTRACTOR'S HIRING OR SUBrNT•RACTING SIGNATURE CERTIFIES THE FOLLOWING:{ <br />'I CERTIFY THAT IN THE PERF -VCE OF THE WGR: FOR WHICH THIS PERMIT IS ISSUED, I`SHALL EMPLOY PERSONS SUBJECT TO WORKER'S ) <br />COMPENSATION LAWS OF CALIF <br />�5/0S �� <br />APPLICANT'S SIGVATURE: � �"" " TITL % i <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. <br />EH 23-0038 ¢' <br />tm OAO"cam - <br />a) I L At CWCO-Vr <br />number 21Y',! 4i -p- l <br />Joe f&W <br />3) AMvLUAQ tes�Lq 4 (Qa,(c.. AQ..+ccf0(- <br />1 <br />