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APPLICATION 3S2 UA'OERGROIR.'7 ';,.VK RETROFIT. OR PIP_NG ' EPAIR PERMIT <br />73IS ?E.'iMI: =X?! -RES 90 DAYS F:C'l THE A?PROV;'= nA:T__ DO NOT wRITE IN .l).r SHADED AREAS. IVD�CA-.E PERK rT pE 9cLOW- <br />_TANK .'L:__Oi IT __ PIPING REPAIR <br />I <br />EPA STTS S i PROJECT CONTACT i TELEpSCNE 1 <br />� }-ACZLZ:Y NA`SE IO <br />(f PHONE <br />I ADDRESS. ` t <br />CROSS STREET' <br />I I <br />T I rnYER/OP-"RAi17R , <br />PHONE t <br />C i CONTRACTOR .AME <br />O . I PHONE 2 i <br />Z` I CONTRACTOR - DR S I U LIC 2 <br />z G?�71,� t CSS Z ; <br />R I INSURER <br />A 1 I+OR`C_COttP_7 I <br />C I OTHER INFO ATZON ' <br />T I 1 <br />PHONE 4 <br />I <br />rrl trrrr. [Illllttl[rrrl r.......r _ I PHONE 2 <br />F <br />--}t11t111111111 cl lllt tf/7111211 t�__ _-_.- — _ <br />I:�-x iIJ T; -'Z_ SIZE CHEMICALS STORED CURR.ENILY/P_REVIOUSLT DATE UST INSTALLED <br />19- <br />T <br />rr ! 39- <br />X I 39- <br />! 39- <br />_1 I <br />i ) 9- I --- -- 1 <br />11111tl1IIIIIIIIfillIIIIIIIIIi!lII111lIIlllftilltliI[IIIIIIIIIItlitf111f1I1lllllilEilllIILII!!I1[1lIIIIiIlllllliIt[tllllll� <br />Z.! APPROVED APPROVED uITii O]NDI:-ON(S) _ DISAPPROVED ! <br />S ATTAaa-I T :7IZ'1C0ND1--IONS) I <br />.4 1 ?LAX RE VIc JE,' -S :TAKE �CL�%�-� f � � DATE � ^ <br />—�1Jill III IIIIIII IIIIIIrlyinnif IIIIIII11IIIIIIi I11[1!1![II[IIllII111lIt[litti[![I1l![tl!!I[llIltlilllilttlt II[IIIIiI!!I!i! <br />1 <br />.1??LICANI HUS: PERFORM ALL WORK IN AGCCRDA_V(,T 'H SAN JOAQUZN COq(I'( O?DD:ANCES. STATE LAWS, AN.) .tLJLiS ,y1D 7,E(lJIJkTZONS Or ( <br />1 <br />Sa?I JOAQUIN C7VNTY PUBLIC HEAL --f Sr"RVIGS_ C:.1 ---a OR LICENSED AGEMI•S S;G,HATJR£ CERTIFIES THE FOLLOWING: 'I CEXTZFY THAT <br />'.'S. PERFORftXKC= OF THE WORK FOR WInCH THIS PF -MIT ZS ISSUED, I S&UL NCr EMPLOY ANY PSRSON " SG" A 'ANNM AS 'TO 2£COHE. 1 <br />SUBJECT TO WORK --V'S COMPENSATIO.V LAWS OF CALZ=O.RMICONiRACTOR•S HI.2 `AK: OR SUSCONTWCI'IHG SIG.vaTA}{IE CERT'I FIE; T3E FOLLOWING:L (TRTIFY TS;;:-- IV THE PERF R2 T OF '.'HE WG.RIC FOR WHICH THIS PERI r IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT -MwORKER•S 1 <br />C'kIPENSATION LAWS OF CALIF0 <br />:+?PLIUNI'S SiGYATURE: <br />4�7T/' DATE <br />B T-LLING INFORMATION= <br />T-ndicate the responsible party to be billed for additional PHS -EEM) staff time e.Mended bevond <br />permit payment coverage per to -Oc- If the party designated below is different than the Perm it <br />applicant, e -g- property owner, the party must acknowledge this responsibility for the biding <br />by si atu; e and date below. <br />a dress�vV Ahaae number cD l (Yt <br />S �gnature <br />-Y_WVtGi I S <br />!E:H 23-0038 <br />G�YI i ►�Si� 6� -" e- ►� �I �Yl �i✓1�SD r - <br />2 . �Ilvvv nvA Ge -�r o�11 D►n � 1S . <br />i <br />