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=7-1999 9:39AH FROH P. 7 <br /> EtNVIRONMENTAL HES.LT'H DIVISION <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br /> THIS PERt4IT EY.PIRES 90 DAYS FROM THF, APPROVAL DATE. DO NOT WRITE IN ANY SILADED AREAS. INDY.CA11E PERMIT TYPE BELOW: <br /> TANK R£;RGFIT ?IPING REPAIR <br /> EPA SITE q PROJECT CONTACT k. TSLEPHCl7E '\ 1 � <br /> U <br /> ? FACILITY W14E L PHONE $ <br /> A ( <br /> C j ADDRESS <br /> t CROSS STRZST T1l�mY.�rL i I <br /> T I OWNER/OPFRATaR ...�. I PHONE <br /> _ I <br /> CONTRACTJR NAME PHONE ,Y <br /> o <br /> NI CONTRACTOP, ADDRESS CA Lri` CLASS <br /> SU I <br /> 'r <br /> INSURE C_ <br /> UN'S �r �� � � �� CSS +r,\ I WORK.cGMP.a I <br /> C I ryTHRR TNFORMATIaN <br /> 1 <br /> OI <br /> I PHCNE t <br /> R C'1i7 Vks <br /> I PHONE 4 <br /> -�IIlI11!!lIIIIIIIIIIIIIIIIIIIII` <br /> TANK�a # TANK SIZE CHEMICALS STORED CURRENTLY/PREV_OUSLY DATE T73T rNSTAUT SD <br /> 1 39 G� <br /> A 39- <br /> K <br /> 39- <br /> 111111111111111111111111r11ilIIIi1f1111111117 <br /> IIIIIIIlIII11EIIT 1 I 1111 11111111111!!!1lltltlitil1f1111111111111l11117I� <br /> L 1 APPROW APPROVED WITH CONDITION(S) t7SoAk'PRGVED 1 <br /> 1 S.ES A'T'TACHMENT WITH CONDITIONS) � ^ /C)Oa ] PLAN REVIEWERS 'JAMS W -ti�L/ DATE <br /> - <br /> IIIII1111111111111111111111111111f11111111111i Tli 11IIIIIIIIIIIII]1111II1111r111!!lllrr1rl111fI11r11� 1111i1I-III'iri-1-1-11I <br /> AP 7-LTCANT 74U:;'7• PERFORM AIL WORK IN ACCORDANCE WITH SAN JO?.QUI\ COUNTY ORDI:7A0TCES, STATE U.WS, A140 RULES ANn REGULATIONS OF <br /> SAN JOACUIN COU'JTY PUPLIC HEALTH SERVICES. OWNER OR. LICENSED A13ENT'3 SIGNATURE CERTIFIES THE FOLLOWING! •I CERTIFY THAT IN <br /> T`HF. PERFORMANCF OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL NOT RNPLOY .ANY PERSON IN sUCH A MANNER AS TO BECOME <br /> SUPJECT TO WORKER'S COMPENSATION LAWS OF C;,LIrOF_NIA.^ CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIPICLS THS YULLOWIN(::I <br /> "I CERTTF': THAT IN THE PERFORMANCE OF THE WORK FOR WHICH .NIS PERMIT IS ISSUED, Y SHALL EMPLOY PFRSONS SUBJECT TO WORKER'S <br /> C.OMPENSA.TION LAWS OF-CZL_IFORNI . <br /> APPL;CAti T'S 5IGNATURE: \J _ T- - (tel \\ TITLE � li� �W Q \� r DATE <br /> i <br /> BILLING INFORMATION. <br /> Indicate the responsible party to be billed for additional FHS-EHD staff time expended beyond <br /> permit payment coverage per tank. if 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 /> Nam +Zt f t?\CrA address %)\� �e hone number �� <br /> Signatur <br /> EH 23-003810 r?jjtVj_t <br /> i <br />