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ENVIkuweitNIAL 11LALIH UIV1SION <br /> • APPLICATION FOR UNFOUND TANK RETROFIT, TANK LINING, OR PIPIN*AIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE 1N ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> TANK REPAIR/RETROFIT 'TANK LINING PIPING REPAIR <br /> EPA SITE # PROJECT CONTACT $ TELEPHONE # � ,\ Z, �Sw�� a <br /> F FACILITY NAME V aCC PHONE <br /> A - � <br /> ADDRESS vko <br /> L CROSS STREET <br /> 1 <br /> T OWNE OPERAT PHONE <br /> Y --A lob (� <br /> OC CONTRACTOR NAME �5r PHONE �I�� --)L <br /> N CONTRACTOR ADDRESS �ou� C CA LIC # `�y�v CLASS _C_ Cvv <br /> T <br /> A INSURER ( ,_ WORK.COMP.#W� JL �S <br /> t aS <br /> TOTHER INFORMATION `���\ \Q�� p\ �� 1,_,e s. <br /> 0 �c�'a� �� 2X�� PHONE # "11 Is_fz <br /> R <br /> PHONE # <br /> Illlillllllllilllllllllllillil <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39 l C�K <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> 9- <br /> 39-39- <br /> P <br /> L �j APPROVED _ APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME'—ja)Ah �� DATE <br /> 'fTi�Ti I I I i iiiTil I I 1 it I I i I�i-iT"i 1 ITi1TTi fiiiTiiTl I I I i I 1 1 1 1 1 1 1 1 1 1 1 I I I I I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFOR71(l." <br /> rJ y' M- <br /> APPLICANT'S SIGNATURE: �Cjk� TITLE L-hiU E6( , DATE ¢ <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PNS-EHD staff time expended beyond permit payment coverage per tank. If the <br /> party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br /> the billing by signature and date below. \ <br /> Name �-�� r 1� i' �i J c. psic, <br /> Mailing Address <br />