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09/1 ./2000 09:52 2094683433 FIFTH FLOOR PAGE 03 <br /> . N ZXVXRONMENTAL RCALTN DIVISION` <br /> APPLICATION ?OR 9=wm TANK RETROFIT, OR PIPING REPAIR PERMIT <br /> THIS pmmIT SXP=BS 90 DAYS FROM THE APPROVAL OATS. DO NOT WRITS iN ANY SEADED AREAS, INDICATE PMMZT TYPE BELOW: <br /> TANA RETROFIT PIPING RSPAIR <br /> r <br /> APA SITE 9 PROSECT CONTACT & TELEPHONE A' <br /> F FACILITY NAME 3 / �� g�u ) -49---' <br /> A i l <br /> C ADDRESS 1 8\ 2.. Co L'e-y GA t-oN <br /> ? ass STREET I <br /> Z <br /> T i OWNER/OPERATORPSG � I PHONE <br /> 4►J '�ki7 I -4 7Jr <br /> ! <br /> C CONTRACTOR NAM . S. PHONE TT - $ZZZ <br /> O <br /> N I CONTRACTOR ADDRESS -:7-01 NI P gleK —, ! CA LIC 9 "ss Cyj $ f1tOZ � <br /> AI INSURER5 COMA //Vs. I WOAEC.CORP.P Z® I q <br /> C I OTEMIL INFOMMATION <br /> 0 ! PHONE ;i ! <br /> I <br /> R ! Pnom 9 I <br /> I1111111111111111111111111111lI <br /> ANX SD Ik T SIZECS�MI •S AD Y/PR.~'VSOUSI.X DATE'V T NSTALi.i;D I <br /> 39- i i I <br /> T I 39- <br /> A I 39- I <br /> i <br /> N I 39- <br /> n 1 39- 1 I <br /> I 39- I i I i <br /> 1 39- <br /> �1111111111111111 1111 I lil 11 11 1111 11 I i 111 1 1111 !1 IJI 1111111111111111111111111111111111111111111111 if <br /> L _ APPROVED APPROVED WITS CONDITION(a _ OTSAPP`aoVED 1 <br /> A iftuWITH CONDITIONS) <br /> :E 1 PLAN REVIfi NAME SATE <br /> —11JIIIIntlullllluli ulnll! 1 11 ! 1 IIt1 t i1 1 I ! iiiulu 1 1 II In11111111� <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COVN7: ORV=e%XCXS, STATE LAWS, AND RL+.:S AIM RSGS7P.ATIONS OF <br /> SAN JOAQVIN COUNTY Mr.:C HEALTH SERVICSS. OWNER OR LICENSED AGENT'S SIGNATSIAS CERTIFIES THR FOLLOWIVG: "I CITIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR W31SC'3 THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A '.MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPINSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONT- C^ING SIGNATUR: CmRTIFT.£S THE FOLLOWINGeI <br /> °I CERTIFY MiAT IN THE PERFORMANCE OF THE WORK VOR WKXCE( T61IS PSRMZT ZS ISSUED,', I SHALL 214PLOY PERSONS SUBJECT TO WORKER'S <br /> COMF_NSATION LARDS OF CA i,^ORM7.A.° �y C� L <br /> AP?LICANT'S SIGNATURE: TITLE' AAk /710 rm' VAT`- • `I <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHs-EED staff time expended beyond <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 /> by signature and date below. <br /> Name address phone number <br /> Signature <br /> EH 23-0038 '"_ _ Vr� <br /> 2) A\t erl woo� <br /> &UIvoa wtuird <br />