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R ►} ^ ENVIRONMENTAL HEALTH DIVISION <br />ti <br />APPLICATION UNDEROROUND TANK RETROFIT, OR PIPING REPAW MIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APP OVAL Ti.NOT WRITE IN ANY SHADED EAS. INDICATE PERMIT TYPE BELOW; <br />TA" PXMOFIT PIPING REPAIR' <br />ePA SITE 1PROJECT CONTACT i TELtPHONi <br />FACILITY NAME ��� ��-a .fin ` -f 0 ••-�.> '-' <br />A El -1. L PHONE 1 L - �c'� •-L. �i C) <br />ADDRESS &300 <br />9So o <br />j CROSS STREET �' _y <br />t I <br />T i OWNER ePLRA PHONE 1 <br />C COtlT'RACTOR NAM �-c'o •,J �.+ ,QC_ PHONE 1 Z0�_ <br />0 v \,g cs�Cv r 7 ' <br />CONTRACTOR ADORES S p� D 1 /,v -t CA LIC 1 3�G��L'\ 1 CLASS <br />R '.vSURER �l f� �/Y 1.� 2 WORK.COMP.Iewl(% 1I 76 Z..� <br />C OTHER INFORMATION <br />0 PHONE 1 <br />z -- <br />PHONE 1 <br />TANK ID I _ T&K..SIZt ` r CHEMICALS STORED CURRZMY/PREVIOUSLY DATE UST INSTALL¢. <br />A ) 1 .--.._-- <br />J1• <br />P �rrrrrlmrrrmTrn n <br />APPROVED APPROVED WITH CONDITION DISAPPROVED " 7 <br />A { .. -_ <br />1� ACfWZNT WITH CONDITIbNS) <br />P"N REVIIWERS NAME \% , R 4 , .-F DATE <br />7L: CAM? MUST PEAfORM ALL WORN IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS CP <br />SAN :O.QUIN COUNTY PUBLIC HEALTH SER S. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT Iv <br />T"'.1 PERFORMANCE OP THE WORAN <br />K FOR WH IS PERMIT IS ISSUED, I SHALL NOT EMPLOY Y PERSON IN SUCH A MANNER AS TO BECome <br />SVBJZCT TO WORXLR'S COMPENSATION LAW •0 CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THS FOLLOW:ham <br />CYRTITY THAT IN TX .P WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO wORKER'S <br />COMPENSATION LAWS Of I <br />AFPL:CANT'S SIGNATURE: \• TITLE *{ pAT9 <br />BILLING INFORMATION: <br />Indicate the responsible party to --bp billed for additional PHS-EHD staff time expended <br />r <br />pemit payment caverage per tank. If the party designated below is different .than riie -ju: <br />applicant, e.g. property owner, the party must acknowledge this responsibility for @he b... <br />by signature and date below.. <br />NameGq&ui A addresayy��� �(�i[.504 of hone number_ Zoe( - <br />g—. a t u r e <br />oe(-gT:ature <br />=r. 23-0038 <br />C,,"64-n�I-C <br />�.� <br />�j <br />s <br />