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Applicant must perfor work in accordance with San Joaquin County ordinance, state laws and rules and regulations of San <br />Joaquin County Public Services. Owner or licensed agent's signature certifies the following: I certify that in the performance of <br />ch i per it <br />the work for which <br />is iss shall not employ any person in such a manner as to become subject to Worker's <br />Compensation la H is Co is hiring or subcontracting signature certifies the following: I certify that in the <br />JfteVo <br />to Im <br />performanc for Z <br />Jh t:Uhiit ip issued. I all employ persons subject to Worker's Compensation laws pf Califqmia. <br />Applicants <br />Billing Information: <br />Title Linda Steiger - President Date <br />Indicate the responsible party to be billed for additional PHS—EHD staff time expended beyond permit payment coverage per tank. If <br />the party designated below is different that the permit applicant, e.g. property owner, the party must acknowledge this responsibility <br />for the billing by signature and date below. <br />Name: Sacramento Equipment Maintenance Company, Inc. <br />2533 Connie Drive - Sacramento - CA 9S815 916-925-2716 <br />Signature <br />Linda Steiger - President <br />v:\ county \ san Joaquin \ env \ forms \ permits \ repairs2 Wo # 106706 <br />