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i ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERL. ,,JD TANK RETROFIT, TANK LINING, OR PIPING REJ-.IR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _TANK REPAIR/RETROFIT _TANK LINING 4 PIPING REPAIR <br /> EPA SITE # ��I, PROJECT CONTACT $ TELEPHONE <br /> F FACILITY NAME f [%� ttVl PHONE # U � <br /> A V �Y <br /> I ADDRESS <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> C CONTRACTOR NAME J(' PHONE <br /> 3`11O 5- 3-53 <br /> l� <br /> N CONTRACTOR ADDRESS I o 'l '. CA LIC # I��+ �/1 CLASS f� �1 <br /> T 1 V +' <br /> R INSURER i_ (y � /� WORK.COMP.# <br /> A rw� <br /> C OTHER INFORMATION <br /> T <br /> 0 PHONE # <br /> GTANK <br /> PHONE # <br /> ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 11000 mAzAlvdA.' <br /> 12.000 _ JAN fC i2.jjp� Uien^Vt'YriR� <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> IIII <br /> P <br /> L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A ( ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE L� <br /> IIIIIIII111III llllllllill II 1111111111 illll 111111 1 II1111111111 11111 I I1111111I111111111111111111111111illllllll <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN 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 IN T PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS FCA FORNIA." <br /> f <br /> APPLICANT'S SIGNAL E`. TITLE / DATE <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 byspjignature and dapptebelow. <br /> Name ��V1,(& 1�� Vth1 e., <br /> �Q� ;�r� ((�� ,-r 11 (HT1 <br /> Mailing Address �YY1yIl VJ/0M, L\7 I uIVW V��� V �-r/� �?�M� 1Wt 4, 0I :oal� �liYiCi <br /> Day Phone Number ( Y �'1 ) /�, <br /> Signature ✓ (�L <br /> EH 23-0038 <br /> 1 <br />