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APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM TH" j1ROVAL DATE. DO NOT WRITE IN ANY SHADED A INDICATE PERMIT TYPE BELOW: <br /> + ITANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # <br /> F FACILITY NAMEPHONf <br /> A -a 2 I `,' S�c E,# k �- V 6 <br /> C ADDRESS <br /> L CROSS STREET <br /> I % r <br /> T OWNER/OPERATORr JJ PHONE # <br /> Y "- 57 <br /> C CONTRACTOR NAME r — PHONE Al p n <br /> N CONTRACTOR ADDRESS oX !CI_ C' CA LIC # CLASS <br /> T k <br /> R INSURER / / WORK.COMP.# <br /> A �!i C;r7 Ccl 7i' r i''/G IC� L(;/Y) C�?. lam/ —� `�7,K 7*-01 <br /> C OTHER INFORMATION <br /> Fr <br /> PHONE #zUy_� Z2(�-� <br /> PHONE # <br /> TANK 10 # TANK SIZE CH IICALS ST ED URRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- 4 O <br /> T 39- <br /> A 39- 1 Li r> Im ti <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> 1111111111111 IIH <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (S E ATT HMEN WITH CONDITIONS) ))�� <br /> N PLAN REVIEWERS NAME DATE vU Q D <br /> IIIllllllll(111111(IIIIIiII I 1111111 III 111111 1 III II 111 111 I I I II Illtll I III IIlI 11111 lllllllllll <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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS Of CAL IFORN " <br /> APPLICANT'S SIGNATURE: ='���� ��� /fi {� <br /> TITLE -� � DATE <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be bitted for additional PNS-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 bilging by signature and date below. <br /> Name <br /> Mailing Address <br />