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• �� <br /> APPLICAiICN FOR UN ROUND TANK RETROFIT, TANK LINING, OR PIPIT ;PAIR PERMIT..' <br /> THIS PERM17 EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br /> I <br /> I I EPA SITE I PROJECT CONTACT 3 TELEPHCNE » <br /> F FAC:L I T Y NAMEC PHONE <br /> Al 3 k <br /> IC ADDRESS <br /> I <br /> L CROSS STREET <br /> I <br /> T I OWNER/OPERATOR I PHONE ". <br /> Y <br /> C I CONTRACTOR NAME <br /> 0 �( Ct, -P, tJ PHONE A S`,�`) �C�`� •-.�=> �>> <br /> N CONTRACTOR ADDRESS .` �.1 w G` .1CA LIC » \yJ�V CLASS *N - � �N <br /> AINSURER At•¢�\Cc.r / .a�S� �'\ Ll i� I WORK.COh1P.»w L 8 �1 CL(� O� i <br /> OTHER INFORMATION �r \ <br /> 7nR�� .(t�� `�� C I PHONE # <br /> I I PHONE I <br /> 111111111111111111111111111111 <br /> TANK 1D 9 TANK SI2E CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39. L :��-. _, <br /> 39- <br /> A 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 111111111 <br /> 9-39-39- <br /> 1111 <br /> _ APPROVED APPTOVED 'JAN CNDIf10N(S) DISAPPROVED <br /> (4E= ATTACHMENT WITH CONDITIONS) <br /> i N PLAN REVIEWERS NAME / / .T DATE /r <br /> i <br /> 1111111 11111111111I11101111111 MI I 111rllll Illl 1n111111 Ill III I mili1111111111111 <br /> i APPLICANT MUST PERFORM ALL WORK IN ACCCRDANCE WITH SAN JOACUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JCACUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCT- OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPRESUR ION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> CERTIFY THAT IN T PERFC MANCE OF TH FOR WHICH IS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> CCMPENSATION LAWS OF CALIFORNIA 4 <br /> i <br /> ^ J <br /> APPLICANT'S SiGNATURE� RL TITLE �2\LCj \At�0.�CG DA1C � <br /> TE ' O <br /> BILLING INFORMATION: <br /> Indicate ;he resoons'ble party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the <br /> party designated below is different than ;he permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br /> the billing by signature and date Cbelow. <br /> Name <br /> v a t <br /> Maiting Acdress t-_ �� \K`w%c,, C1�J�o �3 <br />