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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDEROD TANK RETROFIT, TANK LINING, OR PIPING OR 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 h PIPING REPAIR <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # G <br /> F FACILITY NAME �� rS :S � � S� ��Xxun PHONE <br /> A ' C1�S-]S <br /> C ADDRESS <br /> I <br /> L CROSS STREET <br /> I <br /> T OWNER/ PERATOR`�. PHONE 6#/ <br /> Y hl-4- --ro CS�:I -`9 7 7'r <br /> C CONTRACTOR NAME 1J� L C, m{ y -' L E PHONE it C C (��„ � -- <br /> 0 T 'I <br /> N CONTRACTOR ADDRESS iQ,-Z,jLpXZ Llor I CA LIC # � Di�-7 CLASS Dy` -nor <br /> T <br /> R INSURER E=,� .�f- WORK.COMP.# <br /> A <br /> C OTHER INFORMATION <br /> 0 PHONE # <br /> R <br /> PHONE # <br /> l l 111!I!!1111111111111111111 l l <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> 3 Oj I- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> RiiTll <br /> L =APPROVEDNDISAPPROVED APPROVED WITH CONDITION(S) <br /> A �S rAITTACNMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME­ Urn- DATE (,- 2 - 95- <br /> 111111l111111111111111I Illlillllll 11111111111 liil l I III Illllillltliltli I I1111l1111111111111111111111i1i1111111111 <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 SERVICEES. 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 /> "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FO #iICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: UTITLE l�c � DATE <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed 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 biking by signature and date below. <br /> Name <br /> Mailing Address <br /> Day Phone Number ( ) <br /> Signature <br /> EH 23-0038 <br /> • 1 • <br />