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K <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGR6 TANK RETROFIT, TANK LINING, OR PIPING REP ERMIT <br />Tii� EAMIT EXPIRES 90 DAYS FROM THE AP AL D NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />TANK REPA RETROFIT TANK LINING PIPING REPAIR <br />EPA SITE # PROJEC & TELEPHONE # S <br />F FACILITY NAME ' i PHONE # <br />iA - <br />C ADDRESS S` <br />I <br />L CROSS STREET <br />I <br />T OWN OPERATOR PHONE # Q 7 <br />Y CJ0 +7 •- Q ���% <br />C CONTRACTOR NAME PHONE # <br />0 - <br />H CONTRACTOR ADDRESS D j It VJAI ,G CA LIC # CLASS <br />T gn�� 6 <br />R INSURERAin" WORK.COMP.# <br />A <br />C OTHER INFORMATION <br />TANK ID <br />39- % �%"7i <br />T 39- <br />A 39- <br />N 39- <br />3 39- <br />39 - <br />39- <br />P HII <br />L <br />PHONE # <br />PHONE # <br />TANK SIZEI CHEMICALS STORED CURRENTLY/PREVIOUSLY <br />t7-odw <br />_ _ APPROVEb WITH CONDITION(S) _ DISAPPROVED <br />A r _(SEE ATTACHMENT WITH CONDITIONS) l" <br />N PLAN REVIEWERS NAMEZ&L DATE����%'7 <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 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION CALIFORM IA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PE FORMANCE E WO HH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIO NIA.-- <br />APPLICANT'S SIGNATURE: TITLE DATEJI�� <br />DATE UST INSTALLED <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 />partydesignated 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 �i —•-- - 1. <br />Mailing Address t r ©.k o <br />Day Phone Number (zpq �v <br />Signature�- <br />EH 23-0038 Z. <br />C.e"� /'lGZ..I-uzuc.Y �C+ -G `"� %�� �f?'irY- � ✓�1'+-��-`'-U,2� ��`.'�`_� <br />/J t_ jjPj,1 <br />,Y,� •• /� <br />