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.,�.; ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDER NO TANK RETROFIT, TANK LINING, OR PIPING f.. IR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _TANK REPAIR/RETROFIT _TANK LINING —PIPING REPAIR <br /> EPA SITE » I PROJECT CONTACT 8 TELEPHONE <br /> F FACILITY NAME /> c I PHONE '.� ,>��'�jC7' <br /> A v� <br /> C ADDRESS / <br /> f 1. <br /> L CROSS STREET <br /> I t/ <br /> T OWNER/OPERATOR rj <br /> f ,/ /�-� 1 01 PHONE _ <br /> CO CONTRACTOR NAME J �� - v-f�{ PHONE wu <br /> N CONTRACTOR ADORE Se i— 7 Y /- <br /> J < / (/ CA LIC CLASS <br /> T ! f� <br /> c � jF WORK.CCMP.» <br /> A INSURE? ( _(. ��� <br /> C OTHER INFORMATION <br /> T <br /> 0 PHONE » <br /> R <br /> PHONE » <br /> Ifl l 11 l 11 li!lillllliilillli111 <br /> 39- <br /> TANK ID » TANK SIZE CHEMICALS STORED CURRENTLY/PREVICUSLY DATE UST INSTALLED <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P 1111III fill 111111111111 <br /> L APPROVED APPROVED WITH CCNOITION(S) DISAPPROVED <br /> A � (S TACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME f.� e_< < A DATE <br /> Illtllflilllill(lli111111111IIII I fill1 I]Ifif] I UIl ll�tl1111111111111111 11lifliili11111111111ililfl1111lllilllf <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 /> i 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 COMPENSATICN LAWS OF CALIFORNIA." CONTRACTCR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFC NCS OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> CGMPENSATICN LAWS Of CALIF NI ." 7 <br /> i <br /> APPLICANT'S SIGNATURE: <br />-31LLING 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 /> warty designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br /> the biLCing by, sig at and dacp below- (� <br /> dame ��t� / LQ �5J1✓ i <br /> i <br /> Mailing Addr 5 Zd;( <br /> day Phone � e /�:2�-- ') <br /> oignature Z ,? <br /> --- < <br /> 41 <br /> EH 23-0038 all1 t.-�- <br />