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01-17-1996 09:Z3AM FROM TO 15108958426 P.03 <br /> i <br /> • APPLICATION FOR UNDERL !D TANK RETROFIT, TANK LINING, OR PIPING R. .R PERMIT <br /> I <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> i <br /> TANK REPAIR/RETROFIT TANK LINING PIPING REPAIR <br /> EPA SITE # PRCJEC7 CONTACT & TELEPHONE it <br /> AFACILITY NAME SCO S b� PHONE # <br /> I ADDRESS Vbj S• <br /> L CROSS STREET � � n <br /> I <br /> T OWNER/OPERATOR T _ PHONE # <br /> Y <br /> OC CONTRACTOR NAM �\ PHONE <br /> T CONTRACTOR ADDR SCA LIC # u CLASS A � <br /> RINSURER <br /> A '� G WORK.COMP.#w` c`�`ZS ZZ►S� <br /> C OTHER INF ATIOR <br /> T <br /> D { PHONE # <br /> � R <br /> PHONE # <br /> II!!! IlIIIIfIIllff�!lfIIIIIi <br /> TANK ID 9 1 TANK SIZE CHEMICALS STORED-CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- c2 ion ` NIT <br /> T 39 <br /> A 3 - <br /> H 3 - <br /> K _ � <br /> 1111MM II III IfluffffffW1111111111 III <br /> P <br /> L —/L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> ATTACHMENT WITH CONDITIONS) <br /> Kt LAN REVIEWERS NAME DATE <br /> fffflffllfflllllll Ifffltl 1f fi !f f 11Itflfl 1 ffflffllffll Iflfltff!! ifll <br /> AP .ICANT MUST PERFORMIALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES STATE LAWSS <br /> ANO RULE AND REGULATIONS OF <br /> SA JOACUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> TH P£R�ORMANCE OF THEIWORK 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 /> °IERTIFY THAT IN 7HEjP ORMANCP HE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> C ENSATION LAWS OF CALF Nf " <br /> APF :CANT'S SIGNATURE. ccs TITLE -V\Q\z,r DATE <br /> 3ILLING I FORMATION: <br /> i <br /> Indicate the esponsibte party to be bitted for additional AHS-EHD staff time expended beyond permit payment coverage per tank. If the <br /> warty designs below isldifferent than the permit applicant, e.g. property owner, the party must acknowtedge this responsibility for <br /> the billing by ignature and date below, <br /> yams <br /> gaiting Addrese <br /> Jay Rhone Number < ) <br /> signature -- <br /> I <br />•H 71-0038 f <br /> I � <br /> I � <br /> � I <br /> �f 1 <br /> I <br />