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APPLIC4TION FSR UNJOVNil _':.ttK•RETROFIT, OR PIPING REPAIR PERMIT• <br /> THIS PERMIT EJC?IBES 90 DAYS FRCM TY APPROV:._ DATE_ DO NOT WRITE IN AJ.= SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _TANK R_.:_OFIT PIPING REPAIR <br /> EPA SITE .i ' PROJECT CONTACT i TELEP4CNE @ <br /> FACILI.Y NAME , � <br /> a l `. CTD " PHONE 21� <br /> j ADDRESS <br /> i �(k+ <br /> CROSS STREET _ - <br /> I <br /> Z' I OWNER/OPERATOR <br /> � PIi�ONE <br /> C CONTRACTOR NAME <br /> O • <br /> Int: PHONE 3 <br /> h j CONTRACTOR IRE / f j <br /> CA LIC.2(d'207 � I CLASS�j !�, <br /> WORK-COMP-i Aj�I 1 <br /> a yr <br /> C j OTHER INFORMATION - 1 <br /> T I <br /> O j <br /> PHONE 4 <br /> R � <br /> I I PHONE 3 I <br /> TANK ID >S TANK SIZE CHEMICALS STORED C(IRRENFLY/PREVZOUSL'! DATE Usi INSTALLED <br /> 19- t I 1 <br /> T l 39- t j ttj j <br /> A I 39- <br /> N I 39- <br /> iC I 39- <br /> 1 239- <br /> 9- t 7PPROVED <br /> APPROVED WITH CONDI"_ON(S) DISAPPROVED I <br /> A, I .SEE ATTAC MF-VT WITH CONDITIONS) <br /> 1 <br /> \I 1 PLAN REVIEWERS NAME DATE <br /> —ilililllll11IIIfIH III Uj�Wf ltlll KIM 1 I [ Ill!llllililltllillillllllllllllilltittliililillil [UI 11 llll[11111111111 <br /> aP?LIGAN[ MIS'.' PERFORM ALL WORK IN ACCORDANCE %:Z:Ti SAN JOAQUZN COUNFY OP.DINANC£S. STATE LAWS, AND RULES AND REGULATIONS OF ) <br /> I <br /> >A?i JOAQUIN COUNTY ?CTBLIC HEAL-.I Sc.RVICES. C:-`ZR OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CSZiTZ FY THAT TN I <br /> T'S. <br /> PERFORMANCE OF THE .CORK FOR -WHICH TEiIS P= MIT IS ISSUED, I SHALL NCT EMPLOY ANY PERSON IN SUCH A KANNER AS TO BECOME j <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CAL=FOPNIA.' CONTRACTOR'S HIR''-VG OR SUBCONTRACTING SIGNATURE CERTIFIES TRE HFOLLOWING: <br /> L <br /> I CERTIFY THAT I:I THE P£RFORM:LVCE OF THE WGR:C FOR WHICH THIS PERMIT ZS ISSUED I SHALL EMPLOY PERSONS SUBJECT TO SIORKOL 1 <br /> COMPENSATION AWS OF CALZ RNZA.'� <br /> APPLICANT'S SIGNATURE: �J � � � �I��✓�IJ DATE �l1 <br /> TZTT. 1 1 <br /> $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 per-mit <br /> applicant, e-g. property owner, the party must acknowledge this responsibility for the billing <br /> by ignatu-e and date below. <br /> (� A F! r / A <br /> Nam , �" a ress ) ; all-hone number � <br /> SignatureI <br /> EH 23-0038 <br /> ��Z'1GJS O F j�'y1. <br /> a. <br /> C. <br />