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APPLICATION FOR UND UND TANK RETROFIT, OR PIPING REPAIR PERMIT <br /> :':IIS ?ERMZT EXPIRES 90 DAYS FRCM THE APPROVE,:- DATE. DO NOT WRITE IN <br /> ANY SHA14E AREAS. INDICATE PERMIT TYPE BELOW: <br /> _TANK R=ORT PIPING REPAIR <br /> EPA SITE X ; P OJECT CONTACT 6 TELEPHCNZ <br /> f FACILITY N = PHONE k , <br /> a <br /> C I ADDRESS j <br /> I <br /> L I CROSS STREET <br /> I � <br /> T I OWNER/OPERATOR I PHONE iE <br /> I I I <br /> C j CONTRACTOR NAME ;j A ➢ PHONE 3 Z <br /> O i cG/ f ® I <br /> Ih I CONTRA I,�RESS , I CA LIC 7/„ I CLASS <br /> T L Y is HA[- <br /> RI INS I WORK.COMP-3 <br /> A <br /> C I OTHER INF -.ATION <br /> T <br /> O I I PHONE 4 <br /> R <br /> I PHONE X <br /> ——�l1i111{i{lldltllfill 11111111111 <br /> TANK ZD # TA1;-K SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> i <br /> 39- <br /> T <br /> 9 T i 39- 0 I I <br /> A 1 39- I I <br /> N 1 39- <br /> IC 1 39- <br /> 1 39- <br /> 1 39- <br /> ---�I1111i1{{1[illlllllltllilldl{lllttltlltlltl{I1I 1111{lltt{lllt{tll!{tlllllll 11(t111111t1{1t1111111tlltit111t1tltlill{ltlll(lj <br /> i PROVED APPROVED WITH CONDI-ON(S) DISAPPROVED 1 <br /> A 1 SEE ATTAC'0�4ENT WITH CONDITIONS) ! <br /> y 1 PLAN REVIEWERS NAME DATE dnb-z <br /> —1IIIIIIItlillIII IIll 1 IIIIIIIII III[fill IlifIIIttll{Illttlll{Ili{11{Ililt[!l1lllllllitl11111{Iftttlttt [1111 1fill IIIt1{IIll IIII <br /> A??LICANT MUST ?ERFORM A(RFO <br /> IN ACCCRDA-14CE WITH SAN JOAQUIN COUNT'L ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLI - SERVICES. C--NER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: ^I CERTIFY THAT IN ' <br /> 1 <br /> T?i= PERFORMANC-c OF THE WICH THIS PERMIT IS ISSUED, I SHALL NCT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME I <br /> SUBJECT TO WORKER'S COMP LAWS OF CALZFORNIA_' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES TIRE FOLLOWING:1 <br /> ^Z CERTIFY THAT Z:7 THE PCE OF TT3E WC.R:: F HICH THIS PERMIT IS ISSUED, SHALL EMPLOY ERSONS SUBJECT TO WORKER'SCOMPENSATION :.AWS OF CALA.' <br /> d <br /> :. j <br /> ?PLICANT'S SIGNATURE: DATF <br /> B ILLING 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 s' atu-1 d date below. <br /> Na dd s_ e number <br /> S igna to <br /> EH 23-0038 <br /> LeAC <br /> 1 <br />