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APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br />THIWERNIT EXPIRES 90 DAYS FROM THEOROVAL DATE. DO NOT WRITE IN ANY SHADED Ale INDICATE PERMIT TYPE BELOW: <br />_TANK REPAIR/RETROFIT _TANK LINING L' PIPING REPAIR r <br />EP SITE # PROJECT CONTACT & TELEPHONE # Z Q00r� �� J <br />F FACILITY NAME ;�`�� a/ �a PHONE ig d '��,7 , 1 <br />A �/ e <br />C ADDRESSS7-ep <br />I <br />L CROSS STREET <br />I <br />TOWNER/OPERATOR <br />C CONTRACTOR NAME <br />0 <br />NCONTRACTOR ADDRESS <br />T <br />R IHSUR <br />A <br />C OTHER INFORMATION <br />T <br />0 <br />R <br />PHONE # G 7 - <br />PHONE <br />PHONE # <br />CA LIC # �.—,�- CLASS,4 <br />C WORK.COMP.# <br />PHONE <br />PHONE # <br />II111111lIIIIIIIIIIiiIt1111i1I <br />TA1{K jQ # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />T 39- (� (i "eane-)f, -e 7-_14-43, <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39- <br />Illl <br />P 111-] MITIM <br />L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />A SEE ATTACHMENT WITH CONDITIONS) ✓� S''EI/ T <br />N PLAN REVIEWERS NAME � DATE <br />Ll III IIiIIII IIIl1IIII1 1111 11 III II 11 ! it I II II ill III 1 I I 111111 III IIIl11I111lilllll 1111111 <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 />SU8JECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNI " <br />L?ti ��� <br />APPLICANT'S SIGNATURE: TITLE 1124">/%P DATE <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional PHS-EHO staff time expended beyond permit payment coverage per tank. If the <br />party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br />the billing b �ignature and date bew. <br />L.yC <br />Mai l ing Address �[9 c?_�.c (�� c- <br />z- <br />OAYMEW <br />AUG 19 1998 <br />SAN F'usuc MEAL `ki im, <br />ENVIRONWNTAL- H@ALfiki blvl ou <br />