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APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br /> THJS PERMI•T EXPIRES 90 DAYS FROM IN ROVAL DATE. DO NOT WRITE IN ANY SHADED A� INDICATE PERMIT TYPE BELOW: <br /> _TANK REPAIR/RETROFIT _TANK LINING h PIPING REPAIR <br /> EPA SITE # PROJECT CONTACT & TELEPHONE NeO9)(068 84.3& R,OBEE--,F SJ4AW <br /> AFACILITY NAME �� � X09 PHONE # 7�9� B�2- SSI S <br /> C ADDRESS I S 3 I I -r Rac.Y GA <br /> I <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y 1 01A,Mn/lR �K F30�-+a42-3381 <br /> OC CONTRACTOR NAME c 'S MAInJT�—N,Pa 1JC..E iNL PHONE # <br /> N CONTRACTOR ADDRESS Po bU� 5('01 ) CA LIC # J��O IGj �(P CLASS <br /> T G(o1/D40%44AZ— <br /> R INSURER &OL-7DeKD E-- J�,L L-e WORK.COMP.0 NJWC 54(03 <br /> A <br /> C OTHER INFORMATION <br /> T <br /> 0 PHONE # <br /> R <br /> PHONE # <br /> {iIIIIIIIII1111111Iillllllllll <br /> TANK ID # TANK SIZE CHEMICALS STORED CUR NTL /PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> 3 39- <br /> A 39- <br /> N 39- - <br /> K 39- <br /> 39- <br /> 39- <br /> P II IIMrM <br /> L / APP OV APPROVED WITH CONDITION(S) DISAPPROVED <br /> A Clfl N WIT NDITIONS) L4'1 <br /> N PLAN REVIEWERS NAME DATE <br /> IIIlillllllllillll(I III II 11 I I it ili III I i I 1 illill III IIIIIIIII111 111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF1 111 <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, 1 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 THE7FF�PKCH THISPERMIT IS ISSUED, [ SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA.,. J�g� <br /> APPLICANT'S SIGNATURE: TITLE IY +:DATEv/`/ <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-END 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 billing by signature and date below. <br /> Name <br /> Mailing Address <br />