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I ENVIRONME.`rrAL HEALTH DIVISION <br />APPLICATIOt. _.R UNDERORCKM TANK RETROFIT, OR PIPING REPAI. 0YRMIT <br />THIS PERMIT XXPIRES 90 DAYS ►RCM T -a APPROVAL OATS,Do NOT <br />1fAI-�4� SHADED AREAS. INDICATE PERXIT TYPE BELOW: <br />TR <br />_TANK REOFIT PING RE-DAIR�T�- <br />d N <br />[PA SITE 1 <br />TACILITY HAME <br />A <br />ADDRESS 170 <br />I CROSS STA¢LT< <br />7 I OWNER/OPERATQR <br />Y <br />C CONTRACTOR NA}(I S <br />0 G/ <br />.v CONTRACTOR ADDRESS <br />R ;NSUAEA <br />A <br />C OTHER INFORI(ATION <br />T <br />0 <br />z, <br />MI <br />.................... <br />P <br />L ��i�✓V • lY.l <br />Y PLAN REVIEWERS NAME <br />I I I I I 111111111111111 fTTTTTTTTTTTT <br />PROJICT CONTACT I, TELEPHONE / j BYO � <br />PHONE 1 <br />PHONE 1zo,:-r <br />r <br />CA LIC— <br />CLAS3� U/ /( O <br />�t./�� WORK.COMPA �6 7— <br />PHONE <br />PHONE 1 <br />'--I <br />PHONE 1, <br />TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE VST INSTALLED <br />G.i>\ly l��trl-rte <br />i <br />PLICANT MIST PERFORM ALL HOAX IN ACCORD <br />SAN JOAQVIN COUNTY PUBLIC HYALTR SERVICES <br />TNL PEAFORx"C3 OF THE WORK FOR WHICH THI <br />SUBJECT TO WORKIR'9 PENSATIO LAWS OF <br />CERTIFY THAT IN THY CE Ol <br />C�IPENSATION LAWS OF RNI <br />I <br />_ APPROVED WITH CONDITION(S) DISAPPROVED I I' <br />.(SVI.ArrACHMENT WITH CONDITIONS) <br />—/z I <br />DATE <br />WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAMS, AND RULES AND REGULATIONS OF 11 <br />WNLR OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLONINGI 'I CLRTIFY THAT IN <br />RMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS To sECCME <br />FORMA,' CONTRACTOR'S HIRING OR SVBCONTAACTINO SIGNATURE CERTIFIES THY FOLLOWINC <br />K FOIL WHIC}i THIS PERMIT IS ISSUED, I SH LL EMPLOY PERSONS SUBJECT TO WORKER S <br />APPLICANT'S SIGNATURE: TITLE ,,1L}�-1 DATE <br />i <br />BILLING INFORMATION: <br />Indicate the responsible party billed for additional PHS-EHD staff time expended beyc <br />permit payment coverage per tank. If the party designated below is different .than the Derrr <br />applicant, e.g. property owner, the party must acknowledge this responsibility For the billi <br />by signature and date below. <br />Name � ddresa /O �,C( /Lrf/z hone numb er'7D�/-�d <br />S _gr ur <br />/ <br />1j <br />EH 23-0038 ' <br />y�g.3`{� ' Insper4' <br />3 . sctiuAA4-�c, AppPj r\tM14A& �� ' 311 ;v <br />