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ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGRI ANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERI -?IT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />_TANK RETROFIT PIPING REPAIR <br />EPA SITE # I PROJECT CONTACT 6 TELEPHONE # <br />F FACILITY NAME <br />A <br />C I ADDRESS <br />I ' <br />L I CROSS STREET 1 <br />I <br />T I OWNER/OPERATOR <br />Y <br />C I CONTRACTOR NAME ` <br />0 <br />N I CONTRACTOR ADDRESS r <br />T i <br />R I INSURER��R <br />A <br />C I OTHER INFORMATION <br />T <br />0 <br />R <br />n of,( A �l C-tAV C- , <br />it Innyy'-e- i l� <br />—74/40 e -& <br />PHCNEc:.O% 7 <br />Z <br />� PH(E # <br />pe <br />PHONE <br />CA LIC CLASS <br />7 WORRK..lCOMP . # <br />?HONE 4 <br />J I ?HONE <br />TANK <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- l 1 1aoo0 <br />T 39- Z. ( (u o Q I <br />two a I I I <br />N 39- 1� 1D190 J I I S <br />K 39- I <br />39- ( I I <br />39- <br />P <br />L ( APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />A ' ATTACHMENT WITH CONDITIONS) <br />N ' PLAN REVIEWERS NAMEDATE /( <br />—I 1111111111111 111 If 111111111111111qf <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:I <br />"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />(\� <br />APPLICANT'S SIGNATURE: �J _ 11 4" g�2k- TITLE 0,(r -,-La-, DATE 0 1% <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional PHS-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 />Name �/. J z-)Aqcf.,address 66,2 G4,�„ f lke, Phone numbed 3s y 097;-- <br />Signature <br />S7SSignature J <br />c�- <br />EH 23-0038 <br />1 <br />