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10/20/2000 11:35 2094683411 FIFTH FLOOR PAGE 02 <br />"ImRO—EN-AL zEALTs arnsim <br />"n1(;;a1ON FOR UNDERGROUND TAM RETROFIT, OR P11 -Md It --PAIR PERMIT <br />TRIS ?=MIT EXPIRES 90 DAYS FROM THE APMOVAL DAT -v. 90 NOT OMZ= LIZ ANY SMUM AZAS- INDICATE PERMIT TYPE MSLOW; <br />TANK RETROFIT _ pIpING REPAIR <br />EPA SZTZ A PP=CT CONTACT a TELEPHONE 0 <br />F ;-A:LITY NAME <br />A 6- -f 2sy <br />C ADDRESS <br />CROSS STREET <br />7 OWNER/OPERATOR <br />Y PHONE <br />C I CONTRACTOR NAME <br />a 1,ve P=Nz <br />COWMCTOR ADDRESS 'Bat <br />T CA LIC CLMS <br />R INSURER <br />WORK -COMP -4 <br />---------- <br />A........ . ... <br />C OTHER INFORMATION <br />0 <br />PFON.- 4 <br />PH013 2 <br />TANK ID J$ TANK ZZZE —T —===KXCA1.$ STORED CURRZNTLY/P;F27FOtT9LY bAT2 t?$T =TALLE7 <br />39- <br />7 I 39-_ <br />A 39- <br />39 - <br />X 29- -- <br />39- <br />APPROVED APPROVED VZT% CONDITION(s) DISAPPROVED <br />A t (S£4 ATTA4:FMF-Vr WITH CONDITIONS) <br />?"V RZVXZ'4ZRS NAME DATE <br />APPLICANT MAST PZPFOP-'K ALL KXX IN ACCORDANCE WITH 5AN JOAQUIN COUNTY OPDZNAXCSS. STATE L.AAS, TND JVLss ANP RZOULATTOJWS OF <br />SAN JOAQUIN COUNTY PUBLIC FEALTIT SERVICES. OWNSt OR LIQ9NS--V AGENT'S SIGNATURE CERTZPIM TM FOLLOW111G. C-2*Txz-y TFAT --N <br />TME PERFORMANCE OF THE WORK FOR WHIC24 THIS PERMIT IS ISSUED, 4 SHALL NCT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WQR=-R'S CCMPE—VSATION LAWS OF CALIFORNIA." CONTRACTOR'S SITAINC do SUBCONTRACTING BIWAZ CERTIFIES TV FOLLOWING: <br />TUR Z FOL w <br />-1 CERTIFY TEAT IN THE PVkFORMANCI OF THE WORK FOR WHICH TH;5 PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SURJ-.CT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />I <br />APPLICANT''SZONATO"; TITLE U <br />mal�� <br />BILLING INFORMATION; <br />Indicate the responsible party to be billed for additional PaS-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. W <br />T121A-a6-(-C— CWvie014,qC?474(-, Ne. zias- gaR-6,+jue- ,fit -V° - <br />Name address bU464o04,04. hone number <br />rfi S® <br />Signature Z9, <br />ER 23-003B <br />0 <br />