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ENVLRCNMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGRO"t TANK RETROf IT, OR PL?I'.JG REPAIR PERMIT 419W <br /> APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. IND:CATE PERMIT TYPE BELOW- <br /> '?'HIS PERMIT EXPIRES 90 DAYS FROM T7i <br /> _TANK RETROFIT PIPING REPAIR <br /> PROJECT CONTACT & TELEPHONE 4 111 <br /> aPA 'SITE X ` <br /> PHONE 4"10 -7 <br /> � <br /> C } ADDRESS /4) Z2— �L✓�iC✓O C� �G G� /� / tJ' - !.,�'. C7J�. �Y��/ <br /> I <br /> L I CROSS STREET - <br /> I 4 PHOrJE d } <br /> T i ONE P " I -':4&"" _ CZ <br /> - <br /> PHONE :tOJ/ LPA <br /> C I CONTP.ACTOR NAME y <br /> O 4 } CA LIC Ii '`(t� / I CLASS <br /> N I CONTRACTOR ADDRESS <br /> 10t,' WOR,.CCMP.# <br /> R I INSURER <br /> A I <br /> C I OTHER INFORMATION ' <br /> ?Fore a <br /> � } I <br /> a I PHa:,JV <br /> —illllllllfilll11111Illllllllll1' TANK SIZE 7T,:,:-,C=_bICALS STORE c w�- E IOJ SLY DATE us—, INSTALLED <br /> TANK ID N <br /> } 39-39-39-39-39- <br /> 19_39 _ <br /> ............ <br /> --- 111111111!{ll}l11Ifll U 1lllllf{11l111I1111111l11111 <br /> {{{ �111111i111111111{111111{fl1l1l1lllllllr111111i111{rI11rII111 <br /> APPROVED APPROVED WITH CONOITIONIS! DISAPPROVED f <br /> I} - (SEE ATTACHMENT WITH CONDITIONS) ,�11'fillll <br /> DATF <br /> ?LAN REVIEWERS NAMr111111Iflllllllll{II11111 IIi{�llllll <br /> APPLdCANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQU:N COUNTY ORDINANCES, STATE LAMS, AND RUL S AND <br /> d`T+JI-?.TIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I C?RTIF'1 THA: :M <br /> -E PEAQOR." COUNCE OF THE WORK FOR WHICH THIS PERMIT IS ISSJ3Efl, ? SHALL NOT EMPLOY ANY PERSON T-r1 SUC'--I .7 ''4A.`RrER AS TO BECOME <br /> SUEJEC'I' TO WORKER'S CCM?SYSATION LAWS OF CALIFORNIA." CONTRACT'OR'S HIRING OR SU3CSKALL EMpLOYI PERSONS SUBTCTr-0 WORKER'THE S <br /> ^d CERTIFY THAT IN THE ?ERFORMANCE OF THE WOR FOR WHICH THIS PERMIT IS ISSUED, <br /> CC:JPENSATION LAWS OF CAL:vORNJj" ,{ . 7 �"�''S l�Z,•9-,,A)l <br /> AP?LICANC'9 SIGNATURE: - <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 /> t acknowledge this responsibility for the billing <br /> applicant, e.g. property owner, the party mus <br /> by signature and date below. <br /> Name <br /> Slrm�'S119��Jr1Z,✓addr s /, 1� ��`� phone number <br /> Signature <br /> EH 23-0038 <br /> �: C!fr��i�ctTt �lkc� ANq ` �7•�?� +"3` PR,\00. TCS �P•�� \r.L�w� Com+. <br /> l R �\CJF� \rGSa�1� &Alkr <br /> lwprorr <br /> y � ��.mac\ �. � 7 moa- �-►- twes.► :�s . <br />