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04-04-1996 02:20Ph1 FPO1,1 `-' TO 7720180 P.04 <br /> APPLICATION FOR UNOERGRCUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br /> THIS 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 N PROJECT CONTACT & TELEPHONE # <br /> S A /, B✓ PRONE # I ✓ — y3/b/ <br /> F FACILITY NAME i <br /> 0. <br /> C ADDRESS I <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y *.F/1 /O /,,P <br /> C CONTRACTOR NAME , / PHONE # ,V_ <br /> 0 41 2rL <br /> N CONTRACTOR ADORESS y- O i , f �� CA LTC 0 CLASS <br /> T <br /> R INSURER ✓ WRK.COMP.#� 8p z3`QA' <br /> A <br /> C OTHER INFORMATION <br /> T <br /> 0 PHONE # <br /> R <br /> PHONE R <br /> 1111111111 <br /> TANK 111111111111111 <br /> LANK ID if TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> r 39- [¢°Y9 62 rSt9. /s./.Cd7PF7Fa ��sr <br /> A 39- <br /> N 39. <br /> K 39- <br /> 31. <br /> 39. <br /> JA <br /> APPROVED APPROVED WITH CONDITIONS) - DISAPPROVED <br /> (SEE ATTACHMENT WITH CONDITIONS)PLAN REVIEWERS NAME DATE l� <br /> IIII11111111111l11lI 1 1 I 1111 111 III III 1111 i III(II � 11111111111 <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: el CERTIFY THAT IN <br /> TME 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 15 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." ,, � "" <br /> APPLICANT'S SIGNATURE: TITLEryjptiy�/l,1g�./,r3,tnDATE <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-END staff time expended beyond permit payment coverage par 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 /> Nerve /(/2&L' At'A//I'.id•✓MZ.OF'A///�'` <br /> Mailing Address rp`//Y2 i3.y.vr� //nCf�,tA�/7ge, <br />