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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUONK RETROFIT, TANK LINING, OR PIPING REPA 9RMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE 1N ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _TANK REPAIR/RETROFIT _TANK LINING _ PIPING REPAIR <br /> JA <br /> PA SITE # PROJECT CONTACT 8 TELEPHONE # <br /> ACILITY NAME //TOTTtG.�' ,q._ P,rHONNEE <br /> &o CDDRESS ROSS STREET <br /> PHONE # <br /> WNER/OPERATOR70�A�Lv,a(�SI�. � � O� 9ka -03 <br /> C CONTRACTOR NAME +�„ (q"1' C. 1 P�i.�*Zd `c.. PHONE # �/_ $3P�3ab4'- <br /> H CONTRACTOR ADDRESS i 45 j{�} (L,n "'V`/] (� CA LIC # 3 „j fir' CLASS <br /> TWRK.CONP.# <br /> n2EOG� <br /> R INSURER <br /> A i <br /> C OTHER INFORMATION <br /> T PHONE # <br /> 0 <br /> R PHONE # <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREViWSLY DATE UST INSTALLED <br /> 39- <br /> 3 39- <br /> A 39- <br /> N 39- <br /> K 39- l <br /> 39- <br /> 39- <br /> iii <br /> P APPROVED WITH CONDITIONS) DISAPPROVED <br /> L _ APPROVED — <br /> A (SEE ATTACHMENT WITH CONDITIONS) DATE <br /> N PLAN REVIEWERS NAME ' II' ' "11' " I i' I� �I11111 <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 /> -IB CERTIFY HATER IN THEMPERFORMAN LAOF TH �LRK FORAWHICH THISCPERMITH ISNG OR ISSUED, IICSHALLCTING EMPLOYIGNATURE PERSONS SUBJECTETOTHE WORKERLSWING: <br /> COMPENSAT;ON ORNI .' <br /> ...._ TITLE l Gh/Z�1 ""' DATE <br /> APPLICANT'S SIGNATURE: <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed 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 billing by signature and date below.below. <br /> Name G W�'•� `v <br /> Mailing Address I <br /> Day Phon N ) ^ o 3 7o <br /> n <br /> Signature �4 <br /> EH 23-0038 tN�IRpNM�ERS CES`jN <br /> pEP.M� <br /> 1 <br />