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APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING 09PAI9 PERMIT <br /> ` Ttt9 PE4MIT EXPIRES 90 DAYS FROM THE OVAL DATE. 00 NOT WRITE IN ANY SHADED INDICATE PERMIT TYPE BELOW: <br /> X XXTANK REPAIR/RETROFIT TANK LINING PIPING REPAIR <br /> EPA SITE #CAD982058240 PROJECT CONTACT & TELEPHONE # Stel hen Westerfield ( 408 )942-640 <br /> FFACILITY NAME PHONE # -942,-6140 <br /> C ADORESS1 Z/00 B. Yoe to Stria - CA 95336 <br /> I <br /> L CROSS STREET HigLwdy Highway99 <br /> I <br /> T OWNER/OPERATOR Beck Nick aS PHONE # <br /> T (209 ) 823-7676 <br /> C CONTRACTOR NAME ARI A Division of LAS PHONE # ( 408 ) 942-61 40 <br /> 0 <br /> N CONTRACTOR ADDRESS 1 1 24 Wri le Mil itas CA 950 SA L!C #55$791 CLASS A B C1 0 HAZ <br /> T <br /> A INSURER WORK,COMP.A'C 5 O <br /> C OTHER INFORMATION <br /> T <br /> 0 PRONE # <br /> IIIIlIIItrtlti�Iilt1lllIIIIIII ' <br /> PHONE <br /> TANK 10 # TANK SIZE CHEMICALS STORED'CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 34- 0,(10 87 Qrtane GaanlinP <br /> T 39- 12 000 • 92 Cc ;4 (,sand Ina �® <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A (S,Ei" ATTACHMENT WITH CONDITIONS} <br /> N PLAN REVIEWERS NAME DATE <br /> IIlIlIIIIll I ! IIIIII :!I li <br /> APPLICANT MUST PERFORM ALL,WORK IN;ACCORDANCE WITH SAN JOAQUIN COUNTY CROINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUSLIC NeALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE '..'ORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY!PERSON IN SUCH A MANNER. AS TO BECOME <br /> SUBJECT TO WORKS®'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING, SIGNATURE CERTIFIES THE FOLLOWING- <br /> "[ CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFCRNIA.° <br /> APPLICANT'S SIGNATURE; !O DATE <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-a4D Staff time expended ba-yond permit payment coverage per tank. If the <br /> party designated be(ox is differmnt than the permit applicant, e.g. property owner, the party crust acknowledge this responsibility for <br /> the Silting by signature and date below. <br /> Mailing Address <br /> Dey Phone Numiaer ( } <br /> Zignature <br /> EH 23.0038 <br />