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It ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGMUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE.. 000 '?TRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _TANK RETROFIT Pt MG REPAIR <br /> C' <br /> EPA SITE I PROJECT CONTACT 6 TELEPHONE R <br /> F FACILITY NAME 2-e(3,C '3�GI8 PHONE '(2o C1 g32- <br /> A <br /> Z <br /> Al JJ 77 l <br /> C I ADDRESS 5 3 .� /I � S C� Cl $ 3 `T <br /> I ' <br /> L I CROSS STREET <br /> I I PHONE d <br /> T I OWNER/OPERATOR I _ <br /> YI C <br /> C I CONTRACTOR NAME �(�'\ ty+-� rn }.�l�f���,�1�NL.0 rl�+`.. PH//ONE �1 M��O Sq�� <br /> :1 I CONTRACTOR ADDRESS�O �^ OrUQAOC C I CA LIC k5b[57t0 L-�I/C�LA55 <br /> T I WORK.CGMP.R <br /> R I INSURER <br /> A <br /> C OTHER INFORMATION <br /> O I PROM' 3 <br /> R I PHONE R I <br /> —IIIIIIIIIIIIIIIIIIIIIIIIIII IIIA <br /> CHEHGEAIK/hfSS <br /> yINSTALLED <br /> TANK ID q TANK SIZE ICALS RE � Y/ wOGSDATE US- <br /> URI- <br /> 39 <br /> S <br /> U� - <br /> 39 <br /> 39- 61 <br /> I <br /> L O! 7 I hso� ✓E r y� 6V 6&P <br /> —I <br /> A I 39- Fj <br /> N I 39- <br /> K I 39- <br /> 39- <br /> J9- I <br /> ---'IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII <br /> P <br /> L I APPROVED APPROVED WITH CONDITION(E) DISAPPROVED <br /> A I SE'E ATTACHMENT WITH CONDITIONS) <br /> N I PLAN REVIEWERS 0DATE (® o <br /> —IIIIIIIIIIIIIIIIIIII I I I A I II IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIII� <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS CF <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 /> � <br /> NSATION LAWS OF CALIFORNIA." CONTRACTOR <br /> HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> SUBJECT TO WORKER'S COMP- <br /> 'I CERTIFY -MAT IN THE PERFORMANCE OF THE WORK E ' WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> CCMPENSATION LAWS OF CALIFO A." /,//J��[ L <br /> APPLICANT'S SIGNATURE: TITLE / •�FS J/b K'-A 27 DATE 'O <br /> BILLING 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 /> � / j phone number <br /> address <br /> Nam <br /> Signature <br /> EH 23-0038 L (O C3 3zTL(O <br /> 1 <br />