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_ LNYIKUNMNINL HLALIH UIVISION <br /> APPLICATION FOR UND` UND TANK RETROFIT, TANK LINING, OR PIPING IR 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 # PROJECT CONTACT 8 TELEPHONE #t4o6 4333 <br /> F FACILITY NAME .��1`�( """r—�, �D PHONE # !�C_l <br /> ADDRESS <br /> L CROSS STREET <br /> I <br /> T OLMERPERATO�� PHONE # ZI <br /> C CONTRACTOR NAME PHONE <br /> O <br /> N CONTRACTOR ADDRESS A/ _- / _ CA LIC # -7b6�b ^C� CLASS G(�� <br /> T 'Tcr Ul�l J 7 <br /> R INSURERI WORK.COMP.f14:?,) <br /> A ` v <br /> C OTHER INFORMATION <br /> T <br /> 0 PHONE # <br /> R <br /> PHONE # <br /> TANK 10 # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- —dZ <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P f ffff ffrr fTffm <br /> L APPROVED PROVED WITH CONDITIONS) DISAPPROVED <br /> A ( ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME_ �7 3C <br /> 7-fT7-FT7�TTi77 T i7-F�-Fi-FiT-�-� Ft-F� 1-Fii� <br /> ` Illll lltltttltlltllltlltitlllt tt llttlll[tllll������[tltl _ Z� <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 WH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION A S OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "1 CERTIFY THAT IN THE Paw <br /> WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CAL 4 <br /> APPLICANT'S SIGNATURE: IK -- S TITLE �CftS DATE'1z_22_L <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 bitting by signature and date below. A,�, <br /> HamoCbt�i p 1 �C Pl �F,lCp (� ' t C- <br /> Mailing Address>F'TjT& .'5_65? <br /> IIt <br /> 2 _ Ccs Ja.e ae c l �, <br />