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ENVInu41.L. ,,L ALALlu DIVISION <br /> APPLICATION FOR Ul' 'ROUND TANK RETROFIT, TANK LINING, OR PIPIN PAIR PERMIT <br /> LHIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> ` _TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br /> EPA SITE # PROJECT CONTACT & TELEPHONE Al <br /> F FACILITY NAME /� �r v� TO� # PHONE <br /> A �1 J5,7-0 <br /> / J <br /> 1 ADDRESS 7 T e-7 1 / NTL 11V P <br /> L CROSS STREET L VQ <br /> I [� <br /> T OWNER/OPERATOR PHONE <br /> Y ),:-/74/,/T- G u N TA <br /> C CONTRACTOR NAMES 1 PHONE #�/� 66 r> <br /> 0 7 3 z <br /> N CONTRACTOR ADDRESS L� «' A LIC # <br /> T U D�° C4 S fo s�7�� CLASS e, <br /> A INSURERMd i' (f L1M)P"5471Pv 1A vR#A11ir Lf-) WORK.COMP.#k, G7 779 -,121 <br /> C OTHER INFORMATION <br /> T TT <br /> O <br /> R 4, l Lf (JQ-�r zNS /lC9 /4/0, <br /> PHONE # <br /> [I <br /> PHONE # <br /> llllllllllllllllllllllllllltll <br /> 39- <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> T 39 Ar I <br /> A 39 r?'�6"D _ L <br /> N 39- DC"C, S U /� <br /> K 39- <br /> 39- <br /> 39- <br /> 11lI <br /> P <br /> L APPROVED _ APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> H PLAN REVIEWERS NAME DATE <br /> Ilillilllllllll11111111111111111111IIIIIIIIII 111111 II III II 111 II111 I it 11111111111111111111111111111111111 <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, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: L' 1%"tea// /,?/Y t TITLE /='7 �L� <br /> - �- � DATE <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-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 billing bysignature and date below. <br /> Name It'V <br /> Mailing Address yL/21(4 341 7-v • L0(1'h' <br />