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,3-17-1999 9:39AM MOM P- 7 <br /> a.iVIRONMENTAL HRIJ-TH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br /> THis 1F2RMIT EY.PIIRSS 90 DAY.^-, FROM THE APPROVAL DATE. DO NOT WF.ITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _TS.NR RETRGFIT ?IPING REPAIR <br /> EPA SITE # PROZSCT CONTACT A, TELEPHONE r . Q� �p `.yam <br /> F PACI I L ND2QE A D/ Q VJM 1 P140-M # 6c\ 'A 146 -1 <br /> `�1 P <br /> A ab�� <br /> c ; aonREss rJ d SQ W 1 �s�6i S40c <br /> L i CROSS STREET W GI.S <br /> T I CwNZR/OPF.•RATOR I PHCNE <br /> CONTRACTOR NAMES <br /> LC ,0 f PHONE # Sip Ins•.DL <br /> 0 <br /> N i CONTR;,CTOR ADDRESS ,-1 n \/e21 �\ \l 1�_ ,r I Ci, I,I'_ # 12,`4 � I CLASS A -/�Q� <br /> F I INSURER `7 I �70RK,CCMP.� I-T lJ <br /> T r.T.t.RR ;NFORMATIONy0�17G VZ e- <br /> GI <br /> PHONE U <br /> ( PHGNE A I <br /> —�lltlllii[ililllltltllllllillll� ! <br /> TANK Ip # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DA7•F UST TNSTALLED <br /> ] 39- LL% (rt9J u <br /> K ] 39-_ I <br /> �llilllllilll11111111,111t11rlIIIr11111,1iiiilrllllltlllllllllll�'lTr [ [ 11t 11111111111,,111[Irl,r[1111111111111111111111Y <br /> L ] P-PPRQ= !PPROVED WITH CONDITION(S) pS?.A.P.PROVED ] <br /> X , (EBB ATr?C'*IB T WITH CONDITIONS) [ <br /> -!ll1 111111111111111111 lttllilll1111111111111Uffl-Illiil[Illli[]I11[till[Illi[[[IIIII,Illliilllllllt[Itlillllllllllllllltllll[ <br /> APPLTCANT 11Ui5T PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORD_II ANCES, STATE LT.WS, AND RULrS Arm REGULATIONS OF <br /> SPI: JOAQCIN COUNTY PUDLI� HEhLTH SERVICES. OWNER OR LICENSED A7,5NT'3 SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY ')HAT IN <br /> THE PERFCP.MANCF. OF THE WORK FOR WHICH THIS PERMIT IS ISSUL•D, I SHALL NOT EMPLOY ANY PEASCN :N --UCH A MANNRR AS TO BECOME <br /> SUPJECT TO WORKER'S COMPENSATION =.49 OF CILTPORNIA.^ CONTRAC;I'r,,R'$ HIRING OR SUBCONTRACTING SIGNATURE CERTIPIES 'ng YULLCWIN(::I <br /> "I CERTIFY THAT IN THE PCA,FORMANCE OF THE WORK FOR WHICH THIS FER.MIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> C:MPENSATION LAWS OF CALIFORNIA <br /> APi'LiCANT'S SIGNATURE: u:•�=" TITLE �CL.� 1�+uKA�c2-t` DATE ,g <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time e.:pended beyond <br /> permit payment coverage per tank. 2f the party designated below is different than the permit <br /> applicant, e.g. property owner, the party must acknowledge this responsibility for the billing <br /> by signature and date below_ <br /> Name S�{t Cjy rt q, address \-\\"1 phone number <br /> Signature <br /> EIS 23-0035 <br /> 1 <br />