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't .. ENVIRONM_VT L HEALTH DIVISION <br /> APPLICATION MR UNDERGROUND TANK RETROTIT, OR PIPING REPAIR PERA.. <br /> TRIS PERMIT EXPIRES 90 DAIS IRON THE APPROVAL DATE. DO t1�T WRITS IN ANY SHADED MEAS. INDICATE PERMIT TYPE BELOW: {, <br /> _TANK RETRO/IT _✓/PIPING REPAIR' �� ?__ 6'4Ou/V���F� <br /> EPA SITE N PROJECT CONTACT i TELEPHONE 0 <br /> r FACILITY NAME � PHONE <br /> A J <br /> C ADDRESS 3Z l <br /> S <br /> Ii CROSS STREET <br /> T OWNER/OPERATOR �f 1� PHONE I <br /> C CONTRACTOR NAME,�;_O,�j G PHONE NZnf-le <br /> Y6Y-S33 <br /> 0 <br /> N CONTRACTOR ADDRESS O{�- O CA LIC / Z <br /> T <br /> AI INSURER 'n (�` In I WORK.COMP,ISO/ ` 6 2 _ <br /> C OTHER INFORMATION <br /> TI <br /> 0 <br /> PHONE N <br /> R <br /> PHONE N <br /> —{Il�llllll�TANK I�������������� <br /> ` TANK ID N �� TAN�I�� CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> J9- <br /> T 39- <br /> A <br /> 9- <br /> I __ <br /> N )9- ` <br /> P. )9- <br /> 39- <br /> )9- <br /> 1I I I 11TT i iTTTIT iTi7iTTTii I TTTT <br /> P � <br /> L APPROVED V APPROVED WITH CONDITIONS) DISAPPROVED I <br /> A p J (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME li4'l L : DATE �II Z��!C� ? <br /> Illlllllilllllllllll ������ IIIII I� <br /> PLICANT 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 /> T)+.E 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: <br /> •I CERTIFY THAT IN -OF-THE-WORK._[OR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS FORM <br /> APPLICANT'S SICNATURB: TITLE��D� I"V {a�yC� DATE <br /> Il "001—/ ter <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 sign��r�e and date below. <br /> b <br /> Nam M?adress phone number 2n4 <br /> ignature <br /> EH 23-0038 <br /> 1 <br />