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N_r+" • ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR <br /> OEROROUND TANK RETROFIT, OR PIPING REPAIR P* <br /> TRIS PERMIT LXPIRES 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 N PROTECT CONTACT i TELEPHONE N <br /> FACILITY NAME v <br /> /\ t�' PHONE N'7:��/ �^�•y (�� <br /> A.7 D R E S 5 \iAn 1�/\1/�;L•:s� \1Q GV�G/y�� (S I�``s'-.' <br /> CP.CSS STP.EET <br /> j <br /> CWNEA IOPERATOR I PHONE N <br /> CCKTRACTOR NAM <br /> k Edo <br /> -9,J3 3 <br /> v j CONTRACTOR ADDRESS r . I CA L!C N ,� I CLASS��/ <br /> WORK.COM P.N (o J6 <br /> a`Z-- <br /> 1 :"HER INFORMATION I ^ <br /> t i <br /> PHONE N <br /> . IIIIIIIIIIIIIIIIillllilllllllll I PHONE N <br /> TANK ID N TANK SIZE CHEM CALS STORED /,PREVIOUSLY DATE UST INSTALLED <br /> 39• <br /> )9• II <br /> 39- <br /> 19. <br /> 9-3111111111MUrMTT TTTTTTTTTiTTTfT UD fTm I I I 1 I I If rnI T i <br /> IPPROU0 �APOVED WITH CONDITIONi DISAPPROVED <br /> IS ACHMENT WITH CONDITIONS) <br /> 7:111 REVIEWERS NAME DATE <br /> - <br /> 'llililIIIIIIIIIIIIII TTrfITmIIIII ff I i I i ri a 1 i riumuff 111(111! <br /> ,'LICA.I?T :MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN ,;QAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERV CES. OWNER OR'LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br /> '7E PEP.FOR.'MANCE OF THE WORK FOR WHI THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANWER AS TO BECOME <br /> S*2WECT TO WORKER'S COMPENSATION LAWj OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOW:N,, <br /> CERTIFY THAT IN THE RF CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> CatPENSATION LAWS OF IF IA <br /> APiL:CAt;71 S SIGNATURE: TITLE �' r •" �1' E <br /> _:LLING INFORMATION: <br /> :ndicate the responsible party to be billed for additional PHS-EHD staff time expended <br /> permit payment coverage per tank. If the party designated below is different than the pe=n,: <br /> applicant, e.g. property owner, the party must acknowledge this responsibility for the bill :., <br /> ,,v signature and date below. <br /> ;:amevl�l address33t) UAt_t ,-,phone number?L <br /> gnature <br /> e <br /> -7.w 23-0038 <br /> —�' C��✓� <br /> �-� Uj <br /> 1 <br />