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ENViRUNMENIAL HEALTH DIVISION <br /> 4 <br /> 0-4 <br /> NAPPLiCAT10N FOR UNDER G� TANK RETROFIT, TANK LINING, OR PIPING REPERMIT <br /> � -/0 <br /> ,HSS IPMIT 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 /> EPA SITE # 1 06 PROJECT CONTACT & TELEPHONE # �/Y3i <br /> F FACILITY NAME P��Go (� PHONE # mY V�v <br /> A i M/ 7 <br /> C ADDRESS <br /> I 1 WYE <br /> L CROSS STREET <br /> i <br /> Y OWNER/OPERATOR eco �fo aua C, <br /> PHONE # r 555 <br /> C CONTRACTOR NAME PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS CA LIC # Q 6 CLASS ,n <br /> T o Y1 <br /> R INSURER t/►o ds �, e r WORK.COMP.# y� <br /> A ` ' <br /> C OTHER INFORMATION <br /> T <br /> O ONE <br /> R <br /> ei <br /> H E # <br /> 111111111111111111111111111111 <br /> TANK 10 # TANK SiZE CHEMICALS ¢TO CUENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- i uot? <br /> T 39- <br /> A 39- *.-k <br /> N 39- q'L w <br /> K 39- <br /> 39- <br /> 39- -- <br /> P I I I I TTfi1TTfTiT1TTTTT1TfTfTilT fiT(1TTTTTi1TfTfiTTiT <br /> L APPROVED APPROVED WITH CON IT N(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH N TIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> 11111111111111111111 IIII I III II 1 1 I I II I I 111111 II I I III I I iI 1 1 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SA AOU1N NTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUiN COUNTY PUBLIC HEALTH SERVICES. OWNER OR ICENSE A NT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT iN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT I ISSU , HALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNI ." NT OR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT iN THE PERFORMANCE OF THE WORK FO WH H PERMIT 1S ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFW IA." ( <br /> APPLICANT'S SIGNATURE: TITLE rQ lip <br /> DATE <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be bitted for add'tional PHS-EHD staff time expended beyond permit payment coverage per tank. If the <br /> party designated below is different than the perm* applicant, e.g. property owner, the party must acknowledge this responsibility for <br /> the bi l ling by signature and <br /> +(pdate <br /> ��(below. <br /> ++ <br /> Name W 1 hA �!�(/l/t�Vv"J <br /> Mailing Address "Co /III// oI Or. (jj 66 <br />