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. APPLICATION FOR UNOERGRCUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT $ 26,7 <br /> THIS PERMIT EXPIRES 90 DAYS FROM THQPROVAL DATE. 00 NOT WRITE IN ANY SHADED &. INDICATE PERMIT TYPE BELOW: <br /> NK REPAIR/RETROFIT _TANK LINING _ PIPING REPAIR <br /> EPA SITE X PROJECT CONTACT & TELEPHONE 9 <br /> FF FACILITY NAME ,q ��'/� PHONE A 'Z(� <br /> aDORESs <br /> I .L: p/ l /1 <br /> G CJS <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE <br /> Y <br /> C CONTRACTOR NAME PHONE X <br /> 0 <br /> N CONTRACTCR ADDRESSZD CA LIC 7 CLASS <br /> R INSURER ? WORK.CCMP.-9 A <br /> A I Ts F 000 <br /> C OTHER INFORMATION <br /> T <br /> 0 PHONE 0 <br /> R <br /> PHONE 0 <br /> litiilliliillllillllili1111t11 <br /> TANK IO TANK SIZE CHEMICALS STORED CURRENTLY/PREVICUSLY DATE UST INSTALL-TO <br /> 39- <br /> T 39- <br /> A 39- I <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> I <br /> 9-39- <br /> 39- <br /> P <br /> L _ APPROVED APPROVED WITH CCNOITICN(S)' _ DISAPPROVED <br /> A ,�� (SEE ATTACHMENT WITH C^.NOITICNS) <br /> N PLAN REVIEWERS NAME tx)h7t�•� DATE 0� <br /> 1111111111111111Iiil1lllllll ! I1111111i! ! !! ! IIUI 1!i !!�!!! Il! ! ! !! ! ! llllli !I 1 ! 111111111111! !i U! ! <br /> APPLICANT MUST PERFORM ALL WORK IN AC:CROANCE WITH SAN JOACUIN CCUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATICNS OF <br /> SAN jCACUIN COUNTY PUBLIC HEALTH SERVICES. CWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FCLLCaING: "I CERTIFY THAT IN <br /> THE PERFCRMANCE OF THE WCRK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WCRK-TRIS CCMPENSATICN LAWS OF CALIFCRNIA." CCNTRACTCR'S HIRING OR SUB=NTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WCRK FCR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PE3SCNS SUBJECT TO WORKER'S <br /> CCMPENSATICN LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITL_ 110YAO 0-5 14VA"Al"4•OATE <br /> BILLING INFCRMATICN: <br /> Indicaca the responsible party to be biLLed for additional PHS-:HOstaff time expended beyond permit payment coverage per tank. If the <br /> party designated below is differenc than the permit applicant, e.g. property owner, the party must acknowledge this responsibilicy for <br /> the bi L Ling bysignaturesignature and dace below. <br /> 1 <br /> Name J-5 A Q-\-rp \Q L,VA <br /> Mailing Address 1 RID` E_ g�' Qornl�Ylfw. Ut `L l7�n(d <br /> Day Phone NL=ef <br /> Signature <br /> :H 2-3-9033 <br /> 06 2003 <br /> M' ES <br /> .I <br /> J <br />