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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _TANK REPAIR/RETROf27 _TANK LINING PIPING REPAIR <br /> EPA SITE 1 I PROJECT CONTACT 8 TELEPHONE 1 <br /> F FACILITY NAME <br /> A PHONE 9 <br /> C ADDRESS ' <br /> I 1 <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR <br /> ' PHONE <br /> C CONTRACTOR NAME <br /> 0 DNONE 3 / <br /> N CONTRACTOR ADORE S <br /> TG LIC CUSS/T <br /> R INSURER (�.ii �! <br /> A WORK.COMP.� C/�/ UL U2 761 <br /> C OTHER INFORMATION I 7 <br /> r <br /> t I PHONE <br /> 11111I1111l11I11111111111111i1 PHONE s <br /> TANK ID 4 TANK SIZE <br /> 39- <br /> CHEMICALS STORED CURRENTLY/PREVICU$LY DATE UST INSTALLED <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 1111 1111111 <br /> APP PRO WITH CONDITICN(S) DISAPPROVED <br /> PLAN REVIEWERS NAME l NT WITH CONDITIONS) <br /> 11111111111111111 fill 1111111111111 ! 1111 !1! llllltli lllIIIIIIf1111111111 II II11i111I11111 ltlllll 11111111111 <br /> 111111! <br /> PPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOACIIIN COUNT( ORDINANCES, STATE LAWS, AND RUL-ES AND REGULATIONS OF <br /> ;AN JCACUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN <br /> SUCH A MANNER AS TO BECOME <br /> UBJECT 10 WORKER'S COMPENSATION LAWS OF CALIFCRNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> I CERTIFY THAT IN THE PERF RMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I <br /> C.MPESSATICN LAWS CF GLI R IA." U LL EMPLOY PERSONS SUBJECT 70 'JCRKER'S <br /> PPUCANT'S SIGNATURE: /�L� �h�V <br /> TITL C <br /> NG INFORMATION: <br /> :ate the responsible parry to be billed for additional PHS-EHO staff time expended beyond <br /> • designated below is different than the Pers-;[ Payment coverage per tank_ [f the <br /> fill-in Permit applicant, e_g_ property owner, the parry must aclmouled p0 ty <br /> 4 by sig tore nd to below ge this res ;bili for <br /> ng Address _ <br /> tone Number ( /� <br /> :ure <br /> 0038 I _ <br /> e p— <br /> __ . c <br />