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r ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDE*ND TANK RETROFIT, TANK LINING, OR PIPING IOR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />---`fANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br />EPA SITE # PROJECT CONTACT & TELEPHONE # <br />F FACILITY NAME (),. -, -7 / b PHONE # o2 (j �Z3 7 / <br />C ADDRESS <br />I f / <br />L CROSS STREET <br />I <br />YOWNER/OPERATOR /C r� E #,�� �� -/(— <br />C CONTRACTOR NAME (� PHONE # OZp �7 4 6 g <br />0 <br />N CONTRACTOR ADDRESS -P0 / CA LIC # ` 7 CLASS 14 11A 7 16* <br />T <br />WORK.COMP.# <br />R INSURER <br />A <br />C OTHER INFORMATION q <br />O� PHONE #l; <br />R <br />PHONE #------- <br />TANK <br />I II I I I I l Ii l 111 1111111111 <br />TANK ID # TANK SIZE CHEMICALS OR .D C RENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- l / -7 �' ��ti , �� e` <br />T 39- / L) `77 L _ <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39- <br />IIII <br />P <br />LPP 0VVED =APPROVED WITH CONDITION(S) _ DISAPPROVED <br />A (SE AITT_ACHMENT NDITIONS) i. <br />N PLAN REVIEWERS NAME I� <br />IIIIIIIII IIII IIIIIIIII[IIIIIIIIIIIIrl 11111111111111111111111 11111 II I1 111111111 I11111111111111111IIIIIIIII 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: "1 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 SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I 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 CALIFORNIA." /1� <br />APPLICANT'S SIGNATURE: < < < �:`' `` e ls'r TITLE A"51 1:)e;Jr DATE <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional PHS-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 anddatebelow. <br />Name S. "s /d ,4 , aJT' - !�_- <br />Mailing Address eo 0 %,- �� L / O <br />Day Phone Number 619 I ) O • � I <br />Signature /� !�'%L-/ /�-�Gt-,_.l -' A-DRCieT'- 14 � <br />y <br />EH 23-0038 <br />1 <br />