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APPLICATICH FOR UNDERGROUND TANK RETROFIT, TANK LINING, CR PIPING RE?AIR PERMIT.` <br /> 1 <br /> J IJI S PERMIT EXPIRES i0 DAYS FROM THE ROVAL DATE. DO NOT WRITE IN ANY SHADEO AF INDICATE PERMIT TYPE 3ELCU: <br /> TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br /> EPA SIT' 1 I PROJECT CCNTACT b TELEPHONE 9 <br /> F FACILITY NAME n I PHONE <br /> A <br /> C ADDRESS <br /> f <br /> L CROSS STREET =1 _ <br /> T OWNER/OPERATOR I--PHONE <br /> C CONTRACTOR NAMET t-+� I PHONE = <br /> 0 C-0 <br /> N CONTRACTOR ADDRESS '1 CA LIC CLASS <br /> R INSURER A / �\ % ' WCRK.00MP.0 �— <br /> A LLIa q`L o� <br /> C OTHER INFORMATION "� \ <br /> -Vt, <br /> C> ���3 \,4\ S ?HONE t <br /> PHCNE d <br /> 111111111111111111111111111111 <br /> TANK 10 ;9 TANK SI2E CHEMICALS STORED CURRENTLY/PREVICUSLY I DATE UST INSTALLED <br /> 39- <br /> 7 <br /> 9 <br /> A 39 ...... y i , <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> L <br /> 9- <br /> 39- <br /> 39- <br /> L APPROVED r APPROVED WITH CCNDITICN(S) 01SAPPRCVED <br /> AG gTTACHMENT WITH CCNDIiICHS) <br /> PLAN REVIEWERS MAHEN I1111111i11111111111111111111111111111111111111 I�111 111111111111 11111 IlrIIiI171i111111111IOATE ZIIIII 11111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBL:C HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CEERTIFIEES THE FOLLOWING: ".' CERTIFY THAT IN <br /> THE PERFCRMANC_ OF THE .'ORK FOR WHICH THIS PERMIT IS ISSUED, f SMALL NOT EMPLOY ANY PERSCN IN SUCH A .MANNER AS TO 3ECCME <br /> SUBJECT TO UORKER'S CCMPc TICN LAWS OF CALIFORNIA." CONTRACTOR'S AIRING :R SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT iH T PERFO MA OF TH FOR WHICH IS PERMIT IS ISSUED, I SHALL EMPLOY PERSCHS SUBJECT TO WCRKER'S <br /> COMPENSATION LAWS 09/CAL I FO IAS , <br /> PJ <br /> APPLICANT'S SIGNATU�'; TITLE 2 rC V 0. � DATE — \C\—CV? <br /> J <br /> 3ILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-ENO staff time extended beycrd permit payment coverage per tank. If the <br /> party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge :his responsibility for <br /> the 'billing by signature and date Cbelow. <br /> Name (12(_O 1 1 L, <br /> Mailing Address UI �a a��t2 ryv� Q r �� ?CA WyG.,, Cc, Cw �3 <br />