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THIS PERMIT EXPIRES 90 DAYS FROM THE AP AL DATE. DO NOT WRITE IN ANY SHADED AREA DICATE PERMIT TYPE BELOW: <br /> 1 <br /> ` TANK <br /> REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br /> EPA SITE T I PROJECT CONTACT & TELEPHONE .1 <br /> F FACILITY NAME PHONE I <br /> A <br /> C ADDRESS JI{�✓ 3 n Q 1 <br /> I <br /> L CROSS STREET i <br /> I <br /> T CWNER/OPERATOR /t I PHONE <br /> YI -�� <br /> C CONTRACTOR NAME <br /> "'� PHONE 9 Z®p <br /> 0 7 <br /> N CONTRACTOR ADDRESS 2 CA LIC I CLASS <br /> R INSURER �`G I WCRK.CCMP.M WC �OD <br /> A A l L�D <br /> C OTHER INFORMATION <br /> T <br /> 0 I PHONE I , <br /> R <br /> PHONE M i <br /> liillllllllil!lI1111111111I111 <br /> TANK ID '. TANK SIZE CHEMICALS STORED CURRENTLY/PREVICUSLY DATE UST INSTALLED <br /> 34- <br /> T 39- <br /> A 39- C <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> 111! ImTI'>r1fTITTTTTT'I�IIT <br /> P <br /> L APPROVED APPROVED WITH CONDITICN(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N ?LAN REVIE'-ERS NAME OAT_ <br /> 1111I111111l11111111111 n IIIIIlIIIIIIIIIIIIIIII I I I I I I I I I I IIIIIIIIIIIIIIIIIII!I 1 I IIIIIIIIIIIIIIIIIIII1111111111 11111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JCACUIN COUNTY CROINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN jCACUIN COUNTY ?UBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FCLLCWtNG: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FCR 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 FOLLCWINGJ <br /> "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FCR 'WHICH THIS PERMIT IS ISSUED, t SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: 7271- <br /> __ QpPS /"I/1^��G��" DATE'(`/lDY I <br /> I <br /> LLING INFORMATION: <br /> .dicate the res,cr <br /> csible party to be billed for additional PHS-E90 star; rice expended beyond permit payment coverage per tank. i; ".:.eirty designated below is different than the permit applicant, e.g. prcperty owner, the party must ackncwledge :his respcnsioility for <br /> ie billing by signature and date below. <br /> 3rrte ld ) ` ' Q �/ <br /> ii l Ara address /7 �1 L(j Grp man Ut J��CT C -I � 7ZY2-l2- <br /> 3y Phone NLmcer (�) .X� 1?-1 6+ — <br /> Ignature -- <br /> + z3-•�c3a <br /> 1 <br />