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APPLICATION :OR UNDERGO ^ANK RETROFIT, OR PIPING REPAIR PERMIT 0 <br />:HIS PERMIT EXPIRES 90 DAYS FRCM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />_TANK RETROFIT PIPING REPAIR L 2 <br />EPA SITE X , PROJECT CONTACT 6 TELEP4CNE i{ _ n h�' l,/ f Q - &J .'?/T• <br />F I FACILITY NAME <br />C I ADDRESS {� <br />I ,/ <br />v I CROSS STREET <br />S <br />T I OWNER/OPERATOR <br />I 1 <br />C I <br />CONTRACTOR NAME <br />O ' <br />N I <br />CONTRACTOR ADD S <br />T ' <br />R 1 <br />INSURER <br />A <br />C ( <br />OTHER INFOR,wATION <br />T <br />O <br />R <br />PHONE 11 Uc f <br />� / i <br />i <br />I <br />i PHONE a 1 <br />I <br />to <br />— 31 1 <br />I CA LIC x � o I CLASS �i v �IA� I <br />WORK.COMP.X���w���ZI <br />I I <br />t i <br />I PHONE I <br />t <br />—(lllltilllllllllilllillllltllll� I PHONE � <br />TANK ID p TANS. SIZE CHEMICALS STORED CURRENTLY/ PREVIOUSLY DATE UST INSTALLED <br />I 39- <br />T I 39- 1 - -- <br />A I 39- 1 I I I <br />N I 39- I I I <br />K I 39- 1 <br />I <br />i 39- <br />P139- <br />1 I I <br />I <br />—Illlllitlllllltlllllillllllilllllllillllllllllll1111111111111111111111I1111111111111111t11111111111ii1t111111111111111111111i <br />i. I _ APPROVED ✓ APPROVED WITH CONDIT=ON(S) DISAPPROVED <br />A I (SEE ATTACHMENT WITH CONDI'rIONS) y ! <br />N I PLAN REVIEWERS :IAM �'-'r c DATE � %I <br />—1I1111llllillllfllll 1 11111 111 ! t1i11111111111111111111l11ti11111111111111111111l1�Ilillilllllillllllllllllllt <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF j <br />SAN JOAQUIN COUNTY PUBLIC HEALT'rI SERVICES. O -W ER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br />THE <br />PERFORMANCE OF THE WORK FOR WHICH THIS 2==ti:4IT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CAL:_ORNIA.' CONTRACTOR'S HIa2_NG OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:1 <br />I CERTIFY THAT IN THE PE FORM'NCE OF THE WOR:: FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S ) <br />COMPENSATION LAWS OF 0RNIA_ <br />APPLICANT'S SIGNATURETITL DA .. <br />I <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional PHS-EHD staff time expended bevond <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 />y si tuned date low. <br />bCf <br />N cess_ I/V )ir� hone number <br />Signature <br />EH 23-0038 <br />C-dt��Ta®tiN� <br />V <br />�� <br />�JA.� <br />1 <br />