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ENVIRCN .- AL HEALTH. DIVISION - - <br /> APPLICATION FOR UNDERGR .TANK RETROFIT, OR PIPING REPAIR PERMIT <br /> THIS PERMI� EXPIRES 90 DAYS FROM THE PVRAL DATE. DON WRITE IN ANY SHADED AREAS. ICATE PERMIT TYPE BELOW: <br /> _TANK RETROFIT PIPING REPAIR <br /> EPA SITE k PRCJECT CONTACT a TELEPHONE / <br /> FAC_TLITY NAME WJ PHONE #7Ky <br /> ADDRESS �ryS ••R� �'+ 4� c•�r/ � �GGIJ <br /> .. CROSS STREET L .J <br /> 0 PERATOR PHONE ,7 <br /> YI <br /> CONTRACTOR NAME PHONE # <br /> D yyy::� s a3'J <br /> N CONTRACTOR ADDRESS / / G-. I G :.=C �OW16� <br /> R INSURER IJ/-h WCAR.CO P.� <br /> C I OTHER :NFORMATION <br /> 0 1 PHONE n <br /> R <br /> —1111111111111111111111111111111I I <br /> PHONE a <br /> 39_ i <br /> TANK ID Y ANK SIZE CA MIC GR"D n UST :NSTALLEn <br /> x,En .l /P -' -0 SY DATE i <br /> A I 39- <br /> 39- <br /> K <br /> 9- <br /> 39-K 139- <br /> 39- <br /> 39-- <br /> 1 <br /> 9-39-39-L I APPROVED ECVED WI�CONDITION(S) DISAPPROVED <br /> A 1 E ..0-'U . WITH CONDITICNSIPLAN FEVIEWERS VAM DATE <br /> —1111 IIIIIIIIIIIIIIIIIII�TIIII1111111 IIIIIIIIII111111111111111111111111111111111111111 1111111111111 IIII111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCO.RDANC= WITH SAY .OAQUIN CCUN:Y ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> S:.IJ SCAQUIN COUNTY PUBL:C HEALTH SERVICES. FWNER OR :IENSEO AGENT'S SIGN=7RE CERTIFIES rHE FOLLOWING: CERTIFY THAT. IN <br /> .HE PERFORMANCE OF THE WORK FOR WHICH IS RMIT IS ISSUED, I SHALL NCT EMPLOY ANY PERSON IN SUCH A MANNER .9S TO BECOME <br /> ( SUBCECT TO WORKER'S COMPENSATI N_LA-WS IFORNIA.- :ONTRACTOR'S A:R:NG OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:I <br /> I CERTIFY THAT IN THE PERFO CE OF 44AK_?OR WH ?-SH{S PERMIT ES ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF C T/0 <br /> 4??L:CANC'S S:GNATL'RE: } _ _ : DATE <br /> 37LLING INFORMATION: <br /> indicate the responsible party to be billed for additional PHS-EHD 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 addressN&5e!:� f phone number � — 7 <br /> v <br /> � Sigrature-K�''. �-- <br /> � c4A � <br /> EH 23-0038 <br /> 1 <br />