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APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THI' )VAL DATE. 00 NOT WRITE IN ANY SHADED A. INDICATE PERMIT TYPE BELOW: <br /> /,/TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br /> EPA SITE 2 PROJECT CONTACT & TELEPHONE <br /> F f,AC I L I TY NAME /CPHONE 0 - L E <br /> A <br /> C ADDRESS <br /> I <br /> L CROSS STREET G i�CC11 161cl <br /> f <br /> T OWNER/OPERATOR PHONE T <br /> YI ri-fc .i . / <br /> C CONTRACTOR NAME f PHONE I <br /> 0 ?l7 C.:..L:., S r (i,. e i ,i C i! L!F_ J-o <br /> N CONTRACTOR ADDRESS /fX CA LIC CLASS <br /> T k <br /> R INSURER // c_m r?, WORK.COMP. �^ - -6 <br /> C OTHER INFORMATION <br /> T <br /> 0 PHONE 92 Uy-v3'�,_ z2 C, <br /> R <br /> PHONE X <br /> 1I111111111!lllllilllllllllill <br /> TANK 10 ;V TANK SIZE CHICALS ST ED URRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> A 39- 2 V� <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> 1111 <br /> L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A (SEE ATT HMEN WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE Q O <br /> 1l111111i111111l11111111111 l 11!1111 Ill illlil 11 ill Il 111 11111 1 !1 II 111111 Illi II11 1111! llllll1111! <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCE'S, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGE'NT'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 <br /> OLLOWING:"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 /> / <br /> APPLICANT'S SIGNATURE: >��f ' 'i � TITLE %' -- DATE //o <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-EHO 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 <br /> Mailing Address <br />