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26/27/.2001 13:57 2094681# FIFTH FLOOR PAGE 02 <br />APPLICATION POR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS 9ERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. OO NOT WRITE IN ANY S O90 AREAS. XMXCA.TE PERMIT TYPE EZWWe <br />TANK R�PRAFIT PIPING REPAIR <br />EPA SITE a PROJECT C�Tt` TAC3T & T=M= R <br />F <br />FACILITY PHONE k ��I D) <br />M&?-k' Z <br />,J <br />C <br />{ ADDRESS 35-s-5 vi. HAm ME - L•Ara/E : ry ax m/.i eu . / 520 i'% 1 <br />r <br />L <br />1 CROSS STREET - 1 <br />X <br />T <br />i owNER,oP ATOR (Zj v i Ks ITP K n kers , lA/e- . j PANE C5/02�ks- <br />C <br />i CONTRACTOR NAME 77214.4-tE /Ate . pEDNE a /k) �'70' 7n2o <br />N <br />( CONTRACTOR ADDRESS eZS.ZS W 'auR RW/� 1 ✓A . 1 CA LIC a 1 CLASS { <br />, ,C3 ue i9A�,K, e A� y s <br />T <br />R <br />! INSURER { WORK.COME'.X <br />A <br />C <br />OTHER INFORMATION 1 { <br />T <br />O <br />1 { PRONE 4 <br />R <br />1 1 PHONE <br />!lilililllTANX ifililliltiitl� <br />TANK ID Jk TANK SIZE CHEMICALS STORED CIIARSNTLY/PREVIOUSLY DATE UST INSTALLED � <br />i <br />39- 1 1 1 <br />T i <br />39- 1 ! 1 <br />1 <br />A i <br />39- 1 1 <br />1 <br />K i <br />39- { <br />1 1 <br />i <br />39- ' 1 <br />ilIlililiitiliiiittliill11111]Elifiiilillililiillilill!l11111[l1!!!1 !i 1 1 111111111111 fill 1 1111111111-11111111 <br />L i T_ APPROVED APPROVED WITH CONDITION(S) DISAPPROVED i <br />A i (S££ ATTAC`VICNT WITH CONDITIONS) ! <br />N ! PLAN REVIEWERS NAME DAT£ I <br />—itliliillllitillliilllliiitiilliiiiiiiltliti lii i i ltlli llitiiiillitlltliiiliitiiliitliiiiitlliililliltillll111l1ilitililll <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH STN JOAQUIN COUNTY OMOXVANCi.S, STATE LAWS, AND ROLES AN7 REGULATIONS OF <br />SAN JOAQUIN COUNTY ?UBLIC HEALTR SMICSS. a4NZR OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS P_DRMIT IS ISSUED, I SISALL NOT MIFLOY ANY PERSON IN SUCH A MANNER AS TO BECOMe { <br />SU9.1MCT TO WOAK£R'S COMPENSATION LAWS OF C.lLTFOaZNIAr" CONTRACTOR'S HIR:NG OR SU8CONTQACTING SIGNATURE CERTIFT= THE FOLLCW.NG:� <br />I CERTIFY TETT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PtRMIT 15 155UED, I SHALL EMPLOY PERSONS S'MJECT TO WORKER'S <br />COMPENSATION LAWS OF CALT£ORNXA." 11 <br />APPLICANT'S SIGNATURE: /0 TITLE �%K�1 <br />DATE <br />1 <br />BILLING INFORMATION: <br />indicate the responsible party to be billed for additional PHS-EHD staff tire expended bevo^.d <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 bil'ir_G <br />by signature and date below. <br />Name address phone number <br />Signature <br />EH 23-0038 <br />