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ENVIhU" 1LJ44,1L "cNLltl DIVISION <br /> APPLICATION FOR UNDE*ND TANK RETROFIT, TANK LINING, OR PIPING *R PERMIT <br /> THIS PERMIT 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 # PROJECT CONTACT & TELEPHONE # <br /> F FACILITY NAME PHONE # <br /> A W ► Z13� <br /> C ADDRESS <br /> I <br /> L CROSS STREET 710�� 1 <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y <br /> C CONTRACTOR NAME PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS . C} CA LIC # CLASS A �t <br /> T <br /> R INSURER <br /> A 11-IN3 WORK.COMP.# <br /> C OTHER INFORMATION <br /> T <br /> 0 PHONE # <br /> R <br /> PHONE # <br /> 111111111111111111111111111111 <br /> TANK ID # T NK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE US INSTALLED <br /> 39- L -e CA 1JJ r <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P IIIITTIIIIIT <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> III I11111111111111IIIIIII]it I I III) II111 III lillll 11 III II ill 111 1 I I 111111 IIII1111111 I11111111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN 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 FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPE TIN LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PE FO AONCE OF WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CAL1 ORN A.' <br /> APPLICANT'S SIGNATURE: �/ TITLE fin"' 1E DATE <br /> DATE 4� <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be bitted for additional PHS-EHD 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 party must acknowledge this responsibility for <br /> the billing by signatureanddate below. <br /> Name j 7 1 <br /> Mailing Address "1� �()( 1� (� �!— c1✓1 f'{1Y\e,�v ���5 �� <br />