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07/15/98 15:26 N0.276 IP02 <br /> _ NY1NL+�+npnML NtALIN DtY1510N <br /> APPLICATION FOR UNDERGRK RETROFIT, TANK LINING, OR PIPING REPAIR PO <br /> \ THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY $RADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> 4 1; TANK REPAIR/RETROFIT TARK LINING _PIPING REPAIR <br /> EPA SITE N Ij PROJECT CONTACT i TELEPHONE 0 <br /> F FACILITY NAME kko { PHONE IF <br /> A <br /> C' ADDRESS <br /> I <br /> L CROSS STREET <br /> I <br /> Y OWNER/OPERATOR j G4 a 6 PHONE * 1 S -%5);-, <br /> C CONTRACTOR NAME ti'4ti PHONE 0 <br /> 0 <br /> N CONTRACTOR ADDRESS CA LIC # CLASS <br /> T <br /> R INSURER Q,Ir WORK.COMP./ O <br /> A <br /> C OTHER INFORMATION <br /> T <br /> 0 PHONE TZI <br /> R -- <br /> illllll111U!!l1111111fill fill PHONE A <br /> 10 TANK SIZE CHEMICALS TOREO CURRENTLY/PREYI DATE UST INSTALLED <br /> 39• 1r)% <br /> -6 0/ Al 1'atdi�i <br /> _Lill A .M-JArlin <br /> T 39- <br /> A 39- <br /> N 39- — w — yQrt,�! <br /> K 39rqVt <br /> Iry <br /> - <br /> 39- <br /> 39 <br /> 1111 <br /> P <br /> LAPPROVED APPROVED WITH CONOITION(S) DISAPPROVED <br /> A (SEk WENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME 79 DATE <br /> III Ifill 111111111111 ilii/ <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAK JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING. "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK rOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO MORE <br /> SUBJECT TO WORKER'S COMPENSATION LAWS Of CALIFORNIA." CONTRACTOR'S MIRING OR SUBCONTRACTING 11GRATURE CERTIFIES THE FOLLOWING; <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS Of CALIF !A." <br /> APPLICANT'S SIGNATURE: TITLE ?Mit vi Wfr!)ATE 6-15-25 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-END staff time expended beyond permit payment Coverage per tank, if the <br /> party designated below is different than the permit applicant, e.g. property owner, the perty must acknowledge this responsibility for <br /> the billing by signature and date below. <br /> Name din a �art WS <br /> Mail Ing Address v, r. MR. 00 -f V 6601 <br /> „3 .�►� s v-dc �_ti,.��d2�d-�.� � � ltio c�' r�..v� t y.�b� <br /> X. Gam. ,4""4 �, .• ° <br />