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ENVIRONMSICTAL HEALTH DIVISION <br />APPLICATION FOR UA.GROUND TANK RETROFIT. OR PIPING REPAIR PEA <br />TEIS PERMIT EXPIRES 90 DAYS FROM TRE APPROVAL DATE. 00 NOT WRM IM,ANT SHADED AREAS. INDICATE PERMIT TYPE SELOMt <br />_-TANK RETROFIT PIPING REPAIR' <br />EPA SITE 9 PROJECT CONTACT i TELEPHONE I a <br />r FACILITY NAME PRONE i X 1 <br />A <br />C <br />ADDRESS <br />35t>4 � <br />I <br />L <br />I CROSS STREET -i---I <br />Ls- <br />T <br />OWNE TOR <br />I <br />PfQ1NE 9 <br />^ <br />CONTRACTOR <br />PHONE 'Zd?_ <br />` Zvi <br />0 <br />N <br />I CONTRACTOR ADDRESS <br />CLASS - <br />CA LIC BiQVQL <br />T <br />�� . <br />R <br />I INSURER r <br />-1 <br />WORK. COMP. 9v,0i(� (p Z <br />A <br />C <br />I OCHER INFORMATION <br />T <br />0 <br />I <br />PHONE I <br />R <br />IIIIIillllllllllllllllllllilll <br />PHONE 1 I <br />TAKE ID i <br />71- <br />TANK N , CH41If.Af Y/PREVIOUSLY DATE UST INSTALLED <br />u <br />T 7!- <br />A 7!- <br />N I!• <br />I <br />P 1111 <br />I <br />L <br />APPROVED APPROVP WITH CONDITIONS) DISAPPROVED <br />A <br />( WITH CONDITIONS) a <br />N PLAN REVIEWERS NAME <br />11111111111111111111 <br />DATS _. <br />11111 <br />, <br />PLICANT MOST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDUMMSS, STATE LAWS. AND RULES AND REOULATIONS OF 1 <br />SAN JOAQUIN COUNTY PUBLIC HEALTR SER OWNER OR LICENSED AGENT'S SIONATURE CERTIFIES THE POLLOWINO, •I CERTIFY THAT IN I: <br />THE PERPORMANC! OF THE WORK FOR WNI IS PERMIT IS ISSUED, I S)IALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS -TO BECOME <br />SUBJECT TO WORKER'S COMPENSAT <br />LA OF CALXFORNIIF.• CONTRACTOR'S HIRING OR SUBCONTRJICTING SIGNATURE CERTIFIES TH8 FOLLOWING: <br />•I CERTIFY THAT IN <br />WHICH THIS PERMIT IS ISSUED, I SKALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF <br />• <br />APPLICANT'S SIGNATUAEt <br />TITLE 1GE;J ///JWIL'I�TdDATB 7 ! "� f <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional PHS-EHD staff time.`expended bpyonc <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 billinc <br />by signature and date below. t� <br />Name>6%► a es `� hoe number2-13s� 6 Z _ 2% 3.� <br />Signatur <br />!r <br />EH 23-0038 /k1, �Nt <br />1 <br />