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n6/21/2601 13:57 20946834 FIFTH FLOOR PAGE 02 <br /> 1 1 ... . ;�A­;; 40 <br /> APPLICATXON FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br /> THIS $ERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED ARSAS• ZNOICATE PENNIT TYPE EXWW- <br /> W�TANIt R-e-rAOFZT PIPING REPAIR <br /> EPA SITE B 1 PROJECT CONTACT I TELEPHONE R <br /> F FACILITY NAME /�vJ KS M/1/I�M #/32 ' PHONE 9 Com)p) <br /> A v ►!C i <br /> c I ADDRESS 3.`�3-S VJ N�1 M ME�2 4 4n/E 1'520 qj <br /> r <br /> L CROSS STREET <br /> I <br /> T i OWNER/OPERATOR (9 01 KS T0P /Tl ABETS . IV& . } PHONE 10) 'V#6_a?alks � <br /> 7,CONTRACTOR NAME �y� �/AIL ' PRONE I l�07jk) ;;70 f0_ 70:2-0 <br /> TRis},/L�CE 6✓�I/20 <br /> N CONTRACTOR ADDRESS °25,25 W L3llR,g4wfe- gt✓d � CA LIC p � CLASS � <br /> T , Au e Altr�i�, e R• �,SA <br /> R 1 INSURER I wORK.COMP.k <br /> A <br /> C OTHER INFORMATION I E <br /> T <br /> O I PRONE <br /> R <br /> PHONE i <br /> —�1l1111111ITANX IDf 11II1llI1II, TANK SIZE CHEMICALS STORED CDRRSNTLY/PREVIOUSLY DATE UST INSTALLED <br /> ! 39- 1 1 <br /> T f 39- ! j <br /> A I 39- I I I <br /> N 1 39- ( I I <br /> K 1 79- I I <br /> 1 S9- I I 1 ! <br /> ! 79' I I I <br /> --�fli111311llltllltll11111!11111[I11III1111llllilll1111!l11111111t(131 I 1 1 1!1111!1111 11 1 1 I 11 1 1 1 11 1 <br /> y"I T APPROVED APPROVED WITH CONDITION(S) DISAPPROVED 1 <br /> A 1 ($EE ATTACMZN'i WITH CONDITIONS) <br /> N ! PLAIT REVIEWERS NAME DAT£ <br /> lIllllIII IIIli11III 1111111111[1]illlfifllill 11! ! I E!U[ Illllilillllllll H Iilllilli11111111 Mill III IIIllllllIII llfil1[III 1 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY OaMXNANCSS, STATE LAWS, ANO RULES AND REGULATTONS OF ` <br /> SAN JOAQUIN COUNTY PUBLIC REALTY SF,RVXC35. OWnR WLICENSED AGENT'S SIG.ITATURE CERTIFIES THE FOLLOWING- "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, T SRA" NOT =4PLOY ANY PERSON IN SUCH A MANNER AS TO BECOME I <br /> SUM1ECT TO WOAYMA,S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIR.VG OR SUBCONTkACT2NG SIGNATURE CERTIFIES THS FOLLOW"NG:1 <br /> I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S 1 <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE Q�7�G� t�C1Z- 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 /> Name address phone number <br /> Signature <br /> EH 23-0038 ` <br /> O <br /> V <br />