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APPLIC4TION FOR U6 TANK RETROFIT, OR PIPING REPAIR PERMIM <br /> THIS PERMIT EXPIRES 90 DAYS FRCM THE APPROVA:- DATE. DO NOT WRITE IN AN-Y SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> TANK R=OFIT PIPING REPAIR <br /> EPA SITE X ! PROJECT CON'T'ACT & TELEPHCNE # <br /> F I FACILITY NAM' ` Y'Y1 t PHONE tt <br /> a 1• o!5 - <br /> � (� j <br /> �1n <br /> G I ` <br /> DRESS Gl �l7 l_l\ 5 '�� �J �- C����U N C1 1 <br /> I r (7 <br /> L { CROSS STREET { <br /> Z � <br /> T { OWNER/OPERATORr ^ i PHONE it 0 c) <br /> C j CONTRACTOR NAME G '" ` 1 U Q-0\,�a G C-y.�._,,; : t PHONE 4oq _ 1 , L ` k-",-3 <br /> 3 : { <br /> L u yo <br /> I: { CONTRACTOR ADDRESS CA LIC xl�t( 1 { CLASS C IJ\ { <br /> T v`+ v <br /> R INSURER - { WORK.COMP.3 _ { <br /> A <br /> C { OTHER INFOR:7ATZON { { <br /> T <br /> 0 i { PHONE 4 { <br /> t t <br /> R <br /> { { PHONE 3 I <br /> TANK <br /> --ilillliltllltll11f111IflII <br /> TANK ID q T:..v c: SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 1 39- <br /> T 1 39- ! I I I <br /> A I 39- <br /> N I 39- I I 1 <br /> K 1 39- l { I 1 <br /> 1 39- 1. I I I <br /> 39- <br /> If fill III 11111111IfIfIIIII1III III IIIIIIII111IIIllllliIIIIIIllIII liIllilllllilfllltflllllllilll lilI IIIIIIIIIlllillII <br /> L 1 APPROVED / APPROVED WITH CONDI'_'ION(S) DISAPPROVED 1 <br /> (SEE ATTAC`ir1ENT WITH CONDITIONS) 1 <br /> DATE <br /> —ff111111111111111\1 PLAN REVIEWERS 111'y11�111111 111111 <br /> 111. I1� I illlllllill UIlillllilllifl11111111illllllllilllillifllllilllilllllllllllillli <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY OFDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF ! <br /> I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGEM"S SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN { <br /> 73HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NCT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME { <br /> SUBJECT TO WORKER'S COMPENSATION' LAWS OF CAL:=ORNIA.• CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING-:{ <br /> I CERTIFY THAT IN THE PERF -vCE OF THE WGRY FOR NHICH THIS PERMIT IS ISSUED, SHALL EMPLOY PERSONS SUBJECT TO WORKER'S I <br /> COMPENSATION :.AWS OF CALZF IA.' I'011' <br /> / <br /> APPLICANT'S SIGNATURE: TI E /�%j/�/�� /' A / 1 <br /> Y <br /> /`BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond <br /> permit payment coverage per tamk. 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 s� ature and d t below///��L���_ „ <br /> Nam a dressphone number <br /> Signature <br /> EH 23-0038 <br />