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APPLICATION FCR UNDERG—ND ='ANK RETROFIT, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FRGM THE APPROVA:- DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> TANK R2_ET=OFIT PIPING REPAIR ' <br /> EPA SITE X ! PROJECT CONTACT L TELEPHCNE # - <br /> p I FACILITYNAME PHONE p c9D 9 - ?Q,3 <br /> .A ` �J <br /> C I ADDRESS / I <br /> I <br /> L i CROSS STREET <br /> I � <br /> T I OWNER/OPERATOR PHONE A <br /> I <br /> I oy- - dal <br /> C j CONTRACTOR NAME / PHONE 9oZU 9' I�� ✓ <br /> O � _ - n In <br /> N I CONTRACTOR ADDRESS C / //f/] I CA LIC x I CLASS /, / � <br /> T i /, `s <br /> R [1,�z�uRER ' <br /> y I WORK.COMP.x — , / I <br /> A 1 <br /> C i OTHER INFORAMATION i <br /> T <br /> 0 1 I PHONE i <br /> R t <br /> PHONE x <br /> TANK <br /> —itilllllillllllllllllttlll <br /> TANK ID TAN-K SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED I <br /> i 39- <br /> T ] 39- <br /> A ] 39- l I I I <br /> N ] 39— <br /> K ] 39— I i <br /> ] 39- 1 I I <br /> --�Illllilllllllllilillilil{ilillliililillllllliilillil illllilllllllilil„�iLl�lllilllllilllllllllliillllllililllllillilllllllilll <br /> L 1 APPRO ED APPROVED WITH CONDI'_'ION( DISAPPROVED ] <br /> A I l (SE ENT WITH CONDI"_'I14 PLAN REVIEWERS NAME rIBO-o ] <br /> --A 11111111111111111111111 1 1 11 I Illi li IIiliiliiin illlillllllllill Eli Illlllllliilliliill li Ilii Illil liilinIII <br /> 1 <br /> AP?LICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND .REGULATIONS OF j <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. O:cNRER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'Z CERTIFY THAT IN j <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 COMP ATION LAWS OF CALIFORNIA.' CONTRACTOR'S HLZ_NG OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWINC:I <br /> '1 CERTIFY THAT IN THE ER OCEWF THE WCR;C FOR WHICH .THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S I <br /> COMPENSATION ;.AWS OF <br /> APPLICANT'S SIGNAT'IJRE. <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 /> applicant, e.g. roperty owner, the party must acknowledge this responsibility for the billing <br /> by s' nature ate below. <br /> Na �ldf'�s s hone number <br /> Signature <br /> EH 23-#T-M' I <br /> Z C <br /> 1 <br />