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M <br /> ENVIRONMENTAL HEALTH DIVISIONS `�/ <br /> !- APPLICATION FOR UNDGOUND TANK RETROFIT, TANK LINING, OR PIPING*IR 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 # Z 3Lf 3233 <br /> A <br /> IADDRESS 13ot W E i <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR :1___ PHONE # <br /> (2,0)53 <br /> C CONTRACTOR NAME J l' ! �— PHONE # 9-43 ��� <br /> ,Cx X33 �^ <br /> N CONTRACTOR ADDRESS ` cy ��T ca LIC `# GSL_ CLASS /4 Wi <br /> R INSURER 1,,_)I-A- <br /> „ _) �1 J/”' WORK.COMP.# �✓a_ <br /> A T 1 �GS/✓i <br /> C OTHER INFORMATION ✓� o ) / <br /> T <br /> 0 PHONE # <br /> R <br /> PHONE # <br /> 111111111111111111111111111111 <br /> 39- <br /> TANK ID 4 TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> 111 i <br /> P <br /> L APAPPROVED WITH CONDITION(S) DISAPPROVED <br /> N PLAN REVIEWERS NAME ATTACHMENT <br /> ( ATTACHMENT WITH CONDITIONS} DATE <br /> 1111111111111111111111111111l1111111li1111111 ! !!1li11! !1l11111111l1!!!!!I1 11 Ill1l11!lilliilll IIl 11111 11 1111111111 <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 COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I Sal. EMPL P S NS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNI " / <br /> 7—IAPPLICANT'S SIGNATURE: —«�/ / �� �+ TITLE i <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 party must acknowledge this responsibility for <br /> the biLtiin�g by signatures and date below. <br /> Name <br /> Mailing Address <br /> Day Phone Number ( ) J_J 3 Z 33 <br /> Signature <br /> EH 23-0038 t __Z� <br /> �� / /� . )G� "�Tf C­'_ <br />