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APPLICATION :OR U10, <br /> CUtM TANK RETROFIT, OR PIPING REPAIR PERM* <br /> T IS PERMIT 7-X?IRES 90 DAYS FRCM THSAPPROVAL DATE. DO NOT WRITE IN A�,'y SHADED AREAS_ INDICATE PERMIT TYPE BELOW: <br /> _TANK R=OFIT PIPING REPAIR <br /> EPA SITE X PROTECT CONTACT TELEPHCNE q <br /> `r I cACILITY NAME PHONE q <br /> C ,`ADDRESS <br /> r I <br /> I <br /> I <br /> L. I CROSS STREET <br /> I " <br /> T I OWNER/OPERATOR + r I PHONE q I <br /> C CONTRACTOR NAME /] _ ;" PHONE <br /> CowrRACTOR AS Ess - /� l'l�J I CA LIC * / I CL0.;5 <br /> R I INSURER L ,,� I WORK.COMP.3 // +' r_ <br /> A <br /> C I OTHER INFOR,uATION I <br /> 0 PHONE 4 1 <br /> R <br /> PHONE 3 I <br /> —1 1111{Il[Illilll{ill{{1[tll{{ll� <br /> TANK ID q T:+.ti' SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> I 39- 1 I 1 I <br /> T l 39- <br /> A <br /> 9 A ] 39- 1 i <br /> N I 39- 1 <br /> x l 39-� I I I <br /> 1 39- <br /> I 39-� <br /> ----�ltlllll!l1111111{Ilial{illllll{Ilfllllllll1111!!f{Ililitlllll{Illtlilli11111!{{Itiflliilllflllililll{I{I{Illllllilllill1111f11 <br /> L 1 APPROVED APPROVED WITH CONDI:'IONIS) DISAPPROVED I <br /> :SEE ATTACHMENT WITH CQNDiTIONS) NN 1 <br /> N' [ PLAN REVIEWERS NAM' DATE <br /> —Illlllllil{{{111111 1I1 I1111 II II i I11111111111t1{Itll H ilt[tlfllll{lllllll{I{llllsl l! I{lllltifll!!{lilllllll <br /> APPLICANT MUST PERFORM ALL WORK IN ACCCRDAVCE WITH SAN JOAQUIN COUNTY OP_DINANCES, STATE LAWS, AND RULES AND REGULATIONS Or j <br /> SAN JOAQUIN COUNTY PUBLIC HEAL_:i SERVICES. O NEER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN I <br /> PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A :BANNER AS TO BECOME. <br /> SUBJECT TO WORK-ER'S COMPENSATION LAWS OF CALL=CRNIA.• CONTRACTOR'S HIRTNG OR SUBC RACTING SIGNATURE CERTIFIES TRE FOLLOWING:I <br /> "I CERTIFY THAT IN' THE PERFORMANCE OF THE WOR:C FOR WHICH THIS PERMIT IS ISSUED, I L EMPLOY PERS NS SUBJECT TO WORKER'S � <br /> COMPENSATION :.AWS OF CALIFOkNIA.' <br /> 1 Y D� <br /> r:?PLICANT'5 SIGNATURE: �-l.' `- / TITLE <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 /> umbe>�C?9 11616,332 <br /> Name address f G{.��" hone n <br /> Signature + <br /> EH 23-0038 <br /> CL <br /> a-- �v�. ��-4't��R-• 1r�t��E.• �t-LOP-. -r© �`�<��-� <br />