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ENVIRUNMENIAL HEALTH DIVISION • <br /> 1 ` APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM TIT APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> ✓ TANK REPAIR/RETROFIT _TANK LINING __ PIPINCREPAIR <br /> EPA SITE b PROJECT CONTACT 6 TELEPHONE d <br /> F FACILITY NAME O O PHONE <br /> A ADDRESS <br /> I �. _ CA, CI :;a <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERA OR PHONE 0 <br /> YirOT� r ) 1941 <br /> C CONTRACTOR NAMEC PHONE 9 <br /> O GG Cx <br /> H CONTRACTOR ADDRESS \'l�'1 `.�}` �f-, CA LIC 0 w CLASS h <br /> T <br /> R INSURER U . t WORK.COMP.# C1n 1P t e <br /> A <br /> C OTHER INFORMATION <br /> LI PIS-z- 3- 3 <br /> R2 ' <br /> PHONE d <br /> T <br /> Iillllllllilllllllllllllllll <br /> TANNK ID N TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> 3 39- <br /> A 39- <br /> N 39- <br /> K 39- _ <br /> 39- <br /> 39- <br /> P IIII f171T�TTTTfffTfff M <br /> L APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> I I I I I I I I I I I 111111111 111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAGUIN 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 INT��FORMANCE OF THE WORK FOR WHICH THIS PERMIT' IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS 0 CAL R IA " <br /> ��p <br /> APPLICANT'S SIGNATUE:\ TITLE F 5\lV�l \U DATE �r X17 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-EHD 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 t C, <br /> Mailing Address O! -'1/ Cert 11 <br /> 1 <br /> 3 <br />