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APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br /> THIS P,E�MIT EXPIRES 90 DAYS FROM THE&OVAL DATE. DO NOT WRITE IN ANY SHADED A* INDICATE PERMIT TYPE BELOW: <br /> _TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br /> EPA SITE K PROJECT CONTACT & TELEPHONE A <br /> F FACILITY NAME PHCNE 0 <br /> A <br /> C ADDRESgoo <br /> S <br /> I <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE <br /> Y OC1 <br /> C CONTRACTOR NAME — PHONE <br /> 0 <br /> N CONTRACTOR ADDRESS Z CA LIC 9 CLASS <br /> T <br /> R INSURERWORK,CCMP,* TS <br /> A <br /> C OTHER INFORMATION <br /> T <br /> 0 PHONE <br /> R <br /> PHONE <br /> Illltlilill111111111f1llllltll <br /> TANK ID 9 TANK SIZE CHEMICALS STORED CURRENTLY/PREVICUSLY DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> tlli <br /> P <br /> L APPROVED _ APPROVED WITH CCNDITICN(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> IIIt1IIIIIII11III 1111111111111 11111 it 1 li I 111111111 fI1 fillIIII IIIII1 II 1111111111 1111!11 11111111111111 IIII I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JCAOUIN 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 /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTCR'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 WORK'ER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE DATE <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-e"HD 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 by signature and date below. <br /> Name <br /> Mailing Address iqZ_ 1, -< ,L � n j ` gS2�Z <br /> Day Phone Numder (2.,(yt) 3 6.5 Z y <br /> Signature <br /> -H z3 �o3a <br /> 1 <br />