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-$AN JOAQUIN COUNTY , <br />ENVIRONMENTAL HEALTH DEPARTMENT. <br />304 E WEBER AVE 3PD FLG)c3R . <br />$TOWON. GA 952(12 <br />APPLICATION FGR ONCE <br />RGROUND TANK RETROFIT. OR PIPING REPAIR PERMIT <br />THIS PERMIT. EXPIRE$ 00 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE 6ELOW: <br />_TANK RETROFIT X_PIPING REPAIR/RETROFIT —UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />+----- -------------------- -.• --- ------------^-- <br />------------------ -•- __--_---------+ <br />1 1 EPA S3:TE # 0 PROJECT CONTACT a TELEPHONE # - Q C-�- I <br />S F ; FACTLITY.NAMh`�itWV W ° --------------- <br />--_-..---_^ �--- ......r ------- -___'------I exasP "1fj1 -__-1 <br />4 A +---------- — --------------��------------------------------------- <br />1 .0 1 AOAttEb6 <br />I. L j CROSS STREET-__ -------- - ----------...-^...-I <br />S2 ------------ � V`�'�� • -----^ .._�-----_-. - ----------------------­--­- _..----_--------- <br />I <br />--- . <br />I T I OWLYEtt/OPERATOR/I�- <br />% { ............ ; PHONB#L} <br />I---+------ -----=----r - -------'--------------..----+--- ( -------d <br />_ }} pp - <br />! C cadTRACTOR 1QAiNB j} �j5 to S { PIIVNe AQ� 3 ' CQ�j3 i� _i <br />1 0 +----^---=---- a� ----i-------n-------------------`, -- <br />I N : CotaTRACTOR "D W0_ <br />` _ � uo `1 W 4 1 CA LSC 8 "f 3 R4 r I CGASS B 4 'Pt Z C! IG <br />IT+ — — — -- a-------- --------------=------------- -------------- �d_ 1_ _ `? ... <br />s R 1 7W80R$16 h+ �k45 ►I_ � C 4?k 1 .C�. llalf 8 �_- t <br />---__--_-------*--------------- --i <br />C s OrHFA SNFORdMATIOlt 1 I <br />I T --•------------­------- <br />---- ------ ---^--------------^--------------------...I <br />O 1 - N S PHONE 4 <br />' - I <br />IR w ---------------------^^-^------------' -------i --------- -........n-------- ..- -_- .- <br />1 { P12ONH #- <br />d <br />+---Si4t:II{CIIi11dlSililiill{ii::i1---------•--�-^---- <br />i rl$x SIZE CHEMICALS STOM CMtkmlvLY/PfIEV =LY I DATE UST INSTALL$ { <br />i 3a. i 1 l NO <br />T } 39- 1 1 <br />1 S 34_ <br />1 S <br />S 1 39- <br />+---1111dis:t:;IrII1,111:111, s, j:;;:s;;:{..Is ,ii „ 111111:!1:111.1:1111 s I{ilsr{::; i 1. „ 111{I:II MI IIII i „ I„ I.1 <br />t P S I <br />S L I __ RP7ROVEa APPROVED WETS Coaoft20NSSI AESAPPROVED <br />' A 1 ( 5 ATTACIDSM WET$ COKOXTIONS1 <br />LN N PLAN Fanmw is : pie ! , A! G, aATE 10 - 2-0—D6 ; <br />SISIII{II`Iil.i'i::'t'Y.IS;IL11i1 'i..1 SI4S:III:;:ii t'. '1 IS,Iiliii;11111:11itII IIIIIiii{1{II:IIiiS1IS11if1i1i1t:.:l:: <br />{ APPLICANT MUST:k?IRFORM ALL M= IN ACCORDANCE 7i= 9AN M=IN COUNTY QWX"WC88, STATE LAWS, AND MULES AND RZGOLATX=S OF 1 <br />d SAN "O QVXW 12000TY, INVIRONMENTAI. =MTH OSPARTMSNT. OMW OR 4,1CE9990 AGENT'S SIWATMM CIATIFIHS THS FCXLoWYN3: 12 CERTIFY <br />1 TW YN THE $ERFORM7tNCS OF ESE WORK FOR NMCtH TRE$. MMMY1 28 ISSUED, I'SIMZ WOT irMOY ANY PERSON %V SUCH A'MAMER AS TO S <br />i BECOME still== TO WoBIER'8 COMPENSATION TAM Or' C$LIFORNIA.I CONTRACSaa'S H2RM OR WWCFTRACTINO SIGNATORB.CERTSB'ISS THe } <br />POLLUTUdi "I'CERTIFY THAT Ea 791E PBRPORMANCE OF THS WORK FOR WHICH TKIS 73=7 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO i <br />{ WORKER'S COMPENSATEOW LAWS o8 CALIFORNIA." { <br />I I <br />{. InUTt1111i0f11 nTM011111fT1i11i Ti1Tl}i <br />i <br />BILLING INF01R VIATION: <br />Indicate the responsible party to be billed fa*r additional EHE staff time expended beyond permit payment <br />coverage per tank. If the party designated below is different than the permit -applicant, e.g. property <br />owner, the party must acknowledge this responsibility for the billing by signature and date below. <br />Name' e9n —aL+ tAddress (Q� CadUivlvi �4v����_ Ph ne# gb8-�anX03 <br />