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LNVLAU4-4.11i"L ar-ALllf UIVISION <br /> APPLICATION FOR U0#OUND TANK RETROFIT, TANK LINING, OR PIPI%AIR 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 SITEA' Cal_. Cx,0L.%�ILA1 PROJECT CONTACT b TELEPHONE # /L) � � w�� ,✓ P Z,-r rIcl�. <br /> F FACILITY NAME # � L)rk -rQJt 1� PHONE fy�q Z 13 <br /> A ,1 /+C <br /> C ADDRESS ,3&3-3 D,k ,2r-iEk <br /> I <br /> L CROSS STREET `5-7 AC EC w A L <br /> T OUNER/OPERATOR PHONE # <br /> Y Y� IZ 77 vu C, 2 6-9 gL13-31/ 3 <br /> C CONTRACTOR NAME �N�i 2�tT U '"`J PHONE o i) gg3„SC, <br /> 0 <br /> N CONTRACTOR ADDRESS ZC J7� ��t L _ „TF CA LIC 1 7-z1 ?,-7� CLASS A z <br /> T �` <br /> R I NSURERN R WORK.COMP. l '� <br /> A <br /> C OTHER INFORMATION <br /> T <br /> 0 PHONE 9 <br /> R <br /> PHONE # <br /> 111Pllllllllllllllllllllllllli <br /> TANK 10 # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- 1� K J r .c ,Y Cjl <br /> iT 39 4 _K r£be t <br /> A 39- z K P4 .S iA It t <br /> N 39- k w rAb Ti. aI q t <br /> K 39- <br /> 39- <br /> 39- <br /> 1111 I I I I I If H III IIIIIIIJ III I I I I I I IIH III 1111111111 hillil 111111111 if if]inlimmunmil I I <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> AtSEE ATACHMEHT WIYH CONDITION'5) <br /> � <br /> N PLAN REVIEWERS NAME :4 r' �� � DATE <br /> 11111111111111111111111111111 1111111111111111 "1 Irl111 IT�f�III 111I IIII I I fill I111111111111111111111IfIHIII I I!I IIIII II <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, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: �`� Imo' TITLE �C-' '�'`!`J `� DAT£ 7-91D <br /> BILLING INFORMATION: <br /> indicate the responsible party to be bitted for additional PHS-EHO 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 signaturel and date below. <br /> Name �`i�E25B^+i L�N�T@vC-;G,.J <br /> Mai ting Address ZS�3 .nl1sS j-'-, – S� 'rC S—rccAc-Te y Cyd} '7 J,z0 <br /> dztcL <br /> 16 YY eta q q <br /> /J/-C_ t- 2,17'S-44 <br /> d � <br /> //� <br /> �t1Vti"T6 Gt �c� �Cr r�� s <br /> ,T` i - o a,-,, r J ` lie Ss L(q YY-teal k"fit <br /> I� <br />