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APPLICATION FOR UMgCUND TANK RETROFIT, TAXI LINING, OR PIPINr*AIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FRGM THE APPROVAL DATE. DO NOT 11217E IN ANY SHADED UREAS. INDICATE PERMIT TYPE BELOW: <br /> _TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br /> EPA SITE 0 PROJECT CONTACT b TELEPHCNE 3 "( /-4 i <br /> J <br /> F FACILITY NAME ! PHONE <br /> A , <br /> C ADDRESS 1On <br /> L CROSS STREET <br /> I <br /> 7 OWNER/OPERATOR PHONE <br /> C CONTRACTOR NAME 31--1.5 iz <br /> N CONTRACTOR ADDRESS j'� CA LIC C,,� I CLASS <br /> R INSURER , 'a J c I UCRX.COMP._ <br /> C i OTHER INFORMATION <br /> T ` <br /> 0 1 PHONE 9 <br /> R t <br /> RPHONE ;9 <br /> Illlllililtllilllllitlllllilit <br /> 39- <br /> TANK ID `. TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY � DATE UST INSTALLED <br /> T 39- I <br /> A 39- i <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P 1111ffffMTffffffI I III III <br /> L APPRO �APPROVED ITH CCNDITICH(S) DISAPPROVED <br /> A WITH CONDITIONS) <br /> V ALAN REVIEWERS NAME DATE <br /> 11111 Ili IIIIII11fill! 1(11111111111 1 !!!! 1 !till( 111t111t1t1lllllill! 11 Illltli11111i111i ltttt 1111t111!!I1 lliltt <br /> APPL!CANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JCACUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING_ "1 CERTIFY THAT IN <br /> 4 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 C^CMPENSATICN LAWS OF CALIFORNIA-" CONTRACTOR'S HIRING CR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLCWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, ! jHALL EMPLOY PERSONS SUBJECT TO WCRKER'S <br /> CC:tPENSATION LAWS OF CALIF <br /> APPLICANT'S SIGNATURETIT � (/.// Z <br /> ?41 <br /> E <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be bitted for additional PHS-_HD staff time expended beyond permit payment coverage per tank- If the <br /> party a igrated below is different than the permit applicant, a-g. property owner, the party must acknowledge :his responsibility for <br /> the bi i g by signature XditYZ :v Name r �. <br /> Mailing Addressal " l�r <br /> Day Phone Numbe. ( �L��{j/ <br /> 0 ' V ' [1 <br /> S i g� � <br /> nja'tyure <br /> EH 23-0038 M YVi5-�70 LQA 1 Y VlA--St— [91e V `" <br />