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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UND ND TANK RETROFIT, TANK LINING, OR PIPING &R PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> ®TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br /> EPA SITE # A PROJECT CONTACT & TELEPHONE # 1 <br /> F FACILITY NAMETUC PHONE # <br /> A <br /> ADDRESS <br /> I a U <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR nI ;L�j PHONE # <br /> Y l� <br /> C CONTRACTOR NAMEVl PHONE # G(( W391-1600 <br /> N CONTRACTOR ADDRESS CU i CA LIC # CLASS <br /> T <br /> R INSURER WORK.COMP.# <br /> A <br /> C OTHER INFORMATION <br /> T <br /> 0 PHONE # <br /> R <br /> PHONE # <br /> 11l111!l1111111111111111111111 <br /> 39- N ID #®04L I <br /> 3S l�SIZE CH ICALS ST RED CURRENTLY/PREVIOUSLY DATE-LIST INSTALLED <br /> T 39- [J <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> I <br /> P <br /> lVEO PROVA�WITH ONDITION(S) DISAPPROVED <br /> A S T CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> n minnin I I I mi I I I!I I I I I untifflmini r=1111111 I IIIIII 111111111111111111111111111111111111111111111HIIII II-VI <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 /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERF RMANCE OF THE WORK F R WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALL ORN A." <br /> APPLICANT'S SIGNATURE. TITLE s DATE <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-EHD 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 SDC} iV <br /> Mailing Address tf 4 9 S g L <br /> Day Phone Number ) <br /> Signature <br /> EH 23-0038 <br /> INV <br /> 1 <br />