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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UND.__.ROVND TANK RETROFIT, OR PIPING REPAIR PERM', <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> �03�7LL 8 `alt/ <br /> TANK RBTROPIT PAI <br /> EPA SITE N PROJECT CONTACT 6 TELEPHONE N/\0jIK-& �� (f <br /> r <br /> FACILITY NAME PHONB N <br /> A 7v� <br /> C I ADDRESS C, J� i\j <br /> I f <br /> L I CROSS STREET <br /> I <br /> T I O OPERATOR PHONE N <br /> C CONTRACTOR NAME l _. ��yy S- �.�l-.c% PHONE N Z14cri— ///•_ 3 <br /> NCONTRACTOR ADDRESS X. L, �.��(��' I CA LIC 0309 Co� I CLASSV�+7j� ot-6 <br /> T <br /> R INSURER �/� CCJJ A` M WORK.COMP.NR,-) `L_ [ v <br /> C I OTHER INFORMATION c ! <br /> T <br /> 0 I PHONE N <br /> R -- --- — ---- <br /> I ( PHONE N I <br /> TANK ID N TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 79- _ _I <br /> A 79- I <br /> N 79- <br /> K 79- S I I <br /> 79-39- <br /> II <br /> �III <br /> P <br /> I <br /> L _ APP ED iAPPROVED AITH CONDITION(S) DISAPPROVED II <br /> A K A E ITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> IIIIIIIIIIIIIIIIIIII MIR <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 /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME I <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:I <br /> •I CERTIFY THAT THB WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS PORN • —� <br /> APPLICANT'S SIGNATURE: TITLE�R+% A�}ACyF.i2 DATE <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 /> Na address �,tJ ,phone number;?-vl?— <br /> Signature ,Z <br /> EH 23-0038 <br /> ^ � <br />