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KVIRONMENTAI. HEALTH DiVISION E <br /> �t ;APPLICATION FOR UNDtmcuA:. TANK RETROFIT, TANK LINING, OR PIPING REPATR, IERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE. IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW- <br /> TANK REPAIR/RETROFIT _TANK LINING � PIPING-MPA+R DIIWC-�S—R (ZCII.P4�+M��r <br /> EPA SITE # ti PROJECT CONTACT & TELEPHONE # ��rIT !> �� lI� <br /> FF FACILITY NAME ( PHONE #A EP <br /> C ADDRESSJI&V r C <br /> I <br /> 04 q5?-762— <br /> L CROSS STREET (tAlTt(1 <br /> I <br /> Y OWNS OPERATOR <br /> C CONTRACTOR NAME PRONE <br /> a <br /> N CONTRACTOR ADDRESS CA LIC it CLASS <br /> T <br /> R INSURER WORK.COMP.# <br /> A <br /> C OTHER INFORMATION <br /> T <br /> p PHONE # <br /> R <br /> PHONE # <br /> itltlillltttt111111iIIiIlIlttt <br /> TANK ID 0 TAWS SIZE CHEMICALS STMOOn CURRENTLY/PRtVTOUSLY DATE UST INSTALLED <br /> 39- _ A <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39. <br /> 39- <br /> lilt ! <br /> P <br /> t, APPROVEDAPPROVED WITH CONDITION(S) DISAPPROVED <br /> A ACHMENT WITH CONDITIONS) r <br /> N PLAN REVIEWERS NAME DATE. <br /> IlitiiltlHlIIIIIttI {lli i! li it � t ! Illitlttii s �I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE V;TH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, OLNIR OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING- "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PTNIT 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 MR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS St18JECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." j <br /> APPLICANT'S S - G TITLE L J' DATE <br /> IGNATUR!: <br /> BILLING INFORMATION- <br /> Indicate the responsible party to be billed for addi..tionai PIIS-EHb staff time expended beyond permit payment coverage per tank. If the <br /> party designated below is different than the pera;tlappticant, e.g. property owner, the party must acknowtedge this responsibility for <br /> the bitting by signature and date betow. <br /> T/►�-rte <br /> Name 1 I ' 1�✓LC rTl C—J L�k- <br /> Mai t ing Address0 / <br /> 74 <br /> Day Phone Number �lU ) '— <br /> Signature <br /> 8H 23-0� <br /> Z <br />