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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FRGM THE APPROVAL DATE- 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> TANK REPAIR/RETROFIT TANK LINING <br /> [PING REPAIR <br /> EPA SITE 1 I PROJECT CONTACT b TELEPHONE <br /> F FACILITY NAME / <br /> A PHONE 2 - <br /> C ADDRESS '3 r� <br /> I / <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATO <br /> Y PHONE 'f <br /> C CONTRACTOR NAME <br /> O I PHONE o <br /> N CONTRAC70R ADDRESS <br /> T I <br /> ` p CA LIC 3 <br /> R INSURER rw`„%�07k CLASS <br /> A WQRX. ^MP <br /> 1 � � /LG <br /> - K.C .: <br /> C OTHER INFORM !'ATION <br /> T <br /> t I PHONE 2 <br /> 11111t11111111II1I1111I1IlIIt! PHONE s <br /> TANK ID <br /> 39- <br /> TANK SIZE CHEMICALS STORED CURRENTLY/PREVICUSLY DATE UST INSTALLED <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 1111 <br /> _ <br /> APPROVED APPROV)ED WITH CONDITICN(S) DISAPPROVED <br /> PLAN REVIEWERS NAME � MJ ��� ✓ NT WITH CONDITIONS) <br /> DATE <br /> 1111111111lIIIt11JII!!llllilfilll 1, 11111! lI1I1111I11 11l11111111111i111l1 Il I1111111Ililllall I1 1��Ii111111111111 <br /> 6PPLICANT ?MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> :AN UCAOUIN COUNTY PUBLIC HEALTH SERVICES- OWNER OR LICZ-NSE) AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> 'HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> UBJECT TO WORKER'S COMP .SATICN LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR <br /> I CERTIFY THAT IN THE ER ORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEDSUBCONTRACTING SIGNATURE CERTTFIES THE FALLOWING: <br /> C.MPEYSATION LAWS OF I RN , I SHEMPLOY PERSONS SUBJECT TO WORKER'S <br /> LF ° ALL <br /> :'PLICANT'S SIGNATUR : <br /> tITL �� DATE w d <br /> :NG INFORMATION: <br /> :ate the responsible party to be billed for additional PHS-EHD Staff time expended beyondrmit <br /> • designated below is different than the permit a licant, e_ Pe payment coverage per tank_ if the <br /> _ g- property owner, the parry must acimowledge this responsibility for <br /> 'ill'ing by Signature and date bel <br /> ng Address f <br /> lone NLViber r0 / <br /> Cure <br />