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ENVIRONMENTAL HEALTH DIVISION <br />f- <br />t. we, APPLICATION FOR UNDE TANK RETROFIT, OR PIPING REPAIR PERMIT • <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW - <br />✓TANK RETROFIT PIPING REPAIR <br />EPA SITE # I PROJECT CONTACT & TELEPHONE # M lji s jr-4 —414 C <br />F FACILITY NAME PHONE # <br />C I ADDRESS <br />I <br />L I CROSS STREET 74 E f,�U fin <br />I � � <br />T OWNE I PHONE # <br />C CONTRACTOR NAME ! y I PHONE #�q� <br />0 [� J nJ `f <br />TI CONTRACTOR ADDRESS6 0g / ,0 I �, �y� , I CA LIC CLASS.. ' I /,� /'� L -L n Z. I <br />R I INSURER �� r _ '. w �7i I WORK. COMP . #j I I / 6 <br />A � L�G. <br />C I OTHER INFORMATION I I <br />T <br />0 I I PHONE # I <br />R <br />PHONE # <br />--11IIIIIIIIIIIIIIIIIIIIIIIIIIIIII <br />T K ZD #%�TANK SIZE CHEMICALS STORED CURR�r Y/PREVIOUS..",{ DATE UST INSTALLpED <br />1) / b� O dt�l,Ol� I C a B l.l <br />T 39- ! I I I <br />A I 39- <br />N I 39- <br />K' 39- <br />39- <br />39 - <br />Jill III I fill III I I IIIIIIIIIIIII IIIIIIIIIIII <br />9-39--illIIIIfillIIIIIIIIIIIIIIIIIIIIIIIIIIIIII <br />L ' APPROVED X APPROVED WITH CONDITIONS) DISAPPROVED <br />A I E A7rACHMENT WI CONDITIONS) ] 1 <br />N PLAN REVIEWERS NAME LA0 DATE ��Jolp�r <br />III fill [IIII fill <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 LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:I <br />"I CERTIFY THAT ZN THEML <br />THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF C APPLICAN'T'S SIGNATURE:TITLE �/--BATE <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond <br />permit payment coverage per tank. If the party designated below is different than the permit <br />applicant, e.g. property owner, the party must acknowledge this responsibility for the billing <br />by signature and date below. <br />Named. //Lv_;.�. i✓��addressGf37 /�, (,�}.L,62± 'hone number!51 6(p �gq3 <br />S ignature���► <br />EH 23-0038 <br />1 <br />