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liNVlnuu,.c,li„V uceLlN uIVI SION <br /> + APPLICATION FOR UNDER•f1D TANK RETROFIT, TANK LINING, OR PIPING 0R PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _TANK REPAIR/RETROFIT _TANK LINING -4 PIPING REPAIR <br /> EPA SITE Al PROJECT CONTACT & TELEPHONE # � G1 a L �$^ t1 1 <br /> F FACILITY NAME �.�-n-+ V�"f TJT <br /> A L/, - PHONE # � <br /> ADDRESS <br /> I e �, i —S' <br /> ✓� l�dzV <br /> L CROSS STREET 5 O <br /> 1 lu <br /> T OWNER/OPERATOR y ��// <br /> Y l BL^iT1f�c�S PHONE y��3toy3 <br /> C CONTRACTOR NAME �\_`- , `�� (MF ` ��LQ ,�-_ G PHONE # 1-2 c_1 �b$_�j.1 g <br /> N CONTRACTOR ADDRESS .fojZ>+„dDX SIO- .-r���� 9$�l CA LIC # S4PIS-7(A CLASB _ Dy0 J pesz <br /> R INSURER (� WORK.COMP.# <br /> A 1de_ a r »S C.� , NWG- 3a5SI-- cxz:, <br /> C OTHER INFORMATION <br /> T 55q <br /> R Plag HONE # Z.(Q$_S4 FS <br /> PHONE #"^'! <br /> 111111111111111111111111111111 <br /> 39- <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> T 39- <br /> A 39- <br /> N 39- Tay dAJ S .ot`.06�- t <br /> K 39- <br /> Al <br /> 39- <br /> 39- <br /> I1111111i',TT <br /> G <br /> L <br /> PJAPPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE CHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME X lfJo o �Y/ Vr.Q_®—Ll DATE <br /> I I I I I I I I 111 I I I 11111111 1 11 I'ITI I ITII I i t 1 1 1 1 1 1 1 1 1 I-IiV I 11111111 I I i I I I I I i <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUIN 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 /> 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 THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE L 5 <br /> DATE a'1^ <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. <br /> Name <br /> Mailing Address <br /> 011e �ce �6vt t o>`L J Q/r vz-R-#+J / .9yC f c otN <br /> � Pea"/ A /amu y <br /> LL-Jl.�� <br />