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4a a ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGRO ANK RETROFIT, OR PIPING REPAIR PERMIT 0 <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE ?-= MZT TYPE BELOW: <br /> _TANK RETROFIT X PIPING REPAIR <br /> j 22A SITE # PROJECT CONTACT & TELEPHONE # I <br /> F i ?AC:L:TY :LAME ( ?HONE $ y® i <br /> A / <br /> C i ADDRESS � /� ®h G/ <br /> I r <br /> L i CROSS STREET L H <br /> : r <br /> T j OWNER/OPERATOR j ?HONE # i <br /> Y j f/f��©/K'y �!�'► G , /' <br /> C CONTRACTOR NAME '" . C. '�dZ ,� C� f9 l ?HONE <br /> �J C ,l- D 31f' ��„�.�• l <br /> L / <br /> N i CONTRACTOR ADDRESS ®/ S Q�./ey t, f CA L_c ,� �') 1 c'" 5,4- <br /> T <br /> R i INSURER /! ` WORK.CQMP.A W!z z a 1!3�ii 9 <br /> A <br /> C j OTHER INFORMATION <br /> T j <br /> 0 PHONE S I <br /> j <br /> R <br /> ?HONE # i <br /> TANK <br /> 111tl11111llt1111111t11t <br /> TANK ZD TANK SIZE i a-EMZCAL3 STORED ^JRRENTLY/2RE7ZCUSLY i DATE UST :NSTALLc'D i <br /> I 39- <br /> T t 39- <br /> A l 39- <br /> N i 39- <br /> K t 39- <br /> l 39-39- <br /> t i <br /> --+�111111l11111111tlltlltlttllllt1i1111tilllt11111111111i1i11t11111111tt111t111t1111It111111111111111!!Illllllllllilltllllllttltl <br /> L I PROVED APPROVED WITH CONDITION(S) _ DISAPPROVID I <br /> A t P ATTACIZ!MENT WITH CONDITZCNS) �/ /, l <br /> N t PLAN REVIEWERS NAME :)AT- <br /> -1-111111111111111111111111 [1 fild!till]! <br /> i <br /> APPL:CANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF j <br /> SAN ;OAQUIN COUNTY PUBLIC REALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CER:'_==-S THE FOLLOWING: "Z CER':'- Y THAT :N i <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON --N SUC2A MANNER AS TO BECOME i <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE ?OLLCWZNG:j <br /> "I CERTIFY THAT ZN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT :S :SSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S i <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: <br /> ®. "L T_TLE DATE tJ <br /> i <br /> i <br /> ILLING INFORMATION: <br /> ndicate the responsible party to be billed for additional PHS-EHD staff time <br /> xpended beyond permit payment coverage per tank. If the party designated <br /> elow is different than the permit applicant, e .g. property owner, the party <br /> ust acknowledge this responsibility for the billing by signature and date <br /> elow. <br /> �a <br /> a m e v�- t_s mis address 1133 5- S / 0`fuR phone number 2Z `Ogi - <br /> ignature <br /> H 23-0038 � f1A1 1144, <br /> ot 1-44- <br /> Vc` <br />