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CNVIRONMENIAL HEALTH DIVISION <br /> APPLICATION FOR U' YGRCUNO TANK RETROFIT, TANK LINING, OR PID RE➢AIR PERMIT <br /> LOIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE DERMIT TYPE BELOW: <br /> TANK REPAIR/RETROFIT TANK LINING - PIPING REPAIR <br /> EPA SITE Al PROJECT CONTACT & TELEPHONE Y <br /> F FACILITY NAME �` �•'�_��/�� <br /> A PHONE <br /> C ADDRESS 3/ 3 <br /> I <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR <br /> Y PHONE <br /> CO I CONTRACTOR NAME - lap <br /> PHONE <br /> N CONTRACTOR ADDRESS <br /> T S3S l tJ I CA LIC x �G C(j '� I CLASS A NA <br /> R INSURER - WORK.CcMP.* Sa <br /> A v <br /> C OTHER INFORMATION <br /> T <br /> 0 <br /> R <br /> PHONE 9 <br /> III111f11111111111�i1111111111 PHONE 9 <br /> 39- <br /> TANK ID : TANK SIZE CHEMICALS STORED CURRENTLY/PREVSCUSLY I DATE UST INSTALLED <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> i P 1111 <br /> L APPROVED APPROVED WITH CCNOITICN(S) _ 0[SAPPROVED <br /> A (S E ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME ` GATE r <br /> 1111111111111111111111 111111 illi II 11 111 I1 11 IIIIIIIlIIllll I I I <br /> 1711111 IM1111 111111111 1111 sill I <br /> APPL!CANT MUST PERFORM ALL 'WORK IN AC=RDANC:- WITH SAN JOAQUIN COUNTY ORDINANCE, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AG'c4T'S SIGNATURE CERTIFIES THE FOLL CJl4G: "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 3ECOME <br /> SUBJECT TO WCRKE3'S CMPE4SATICN LAWS OF CALIFORNIA." CONTRACTOR's HIRING OR SUBCONTRACTING SIGNATURE CERT!FIES THE FOLLOWING: <br /> CERTIFY THAT 14 THE PERFORMANCE CF THE 'WORK FOR WHICH THIS PERMIT !S ISSUED, I SHALL E'1PLOY PERSONS SUBJECT TO WORKER'S <br /> CCMPENSAT!ON LAWS OF CALIFORNIA." <br /> /������• �J/I�/Sry ,lJ�.yjt /AYJ��'i416jC,T ��S/� /T �j�[ G � <br /> APPLICANT'S SIGNATURE: t/"'r- "�'f� •V/�S`/6�'L O� TITLE "^-I i?,pa &46/ A'E 1.Z1. 7 <br /> u <br /> I <br /> 3ILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional ?4S-=HD staff, time expended beyond permit payment coverage per tank. [` the <br /> carry designated below is different than the pemit applicant, e.g. property owner, the parry must acknowledge this responsibility Por <br /> the biLling by signaturend date below. <br /> Name <br /> ..Mailing Address ,.r U <br /> DaY Phone 4moer (F1l/)_.. J✓J- h1)3 <br /> Signature <br /> E:H Z3.0038 <br /> 1 <br />