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APPLICATION FCR UN40OUND TANK RETROFIT, OR PIPING REPAIR PERMITO <br />THIS PERMIT EX?TRES 90 DAYS FRCM TP-- APPROVA,. DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />_TANK RETROFIT PIPING REPAIR <br />EPA SITE X I PROJECT CONTACT L TELEPtiCNH Y A L�-r 1,-) 9 t -%n -A I. l f <br />F FACILITY NA -Mr - <br />I <br />ADDRESS <br />L CROSS STREET <br />-T <br />v I <br />OWNER/OPERATOR <br />C j <br />O , <br />CONTRACTOR NAME <br />lv I <br />T <br />CONTRACTOR ADDRESS <br />R <br />INSURER <br />A <br />C <br />T I <br />OTHER INFORMATION <br />O <br />R <br />' PHONE 3 I <br />---�1I11111[illllllltt1I111111I111� <br />TANK ID 9 TA -v" SIZE CHEMICALS STORED CURRENTLY/ PREVIOUSLY DATE UST INSTALLED <br />1 <br />39- <br />T <br />9 T I 39- 1 1 <br />A I 39- <br />N I 39- <br />K I 39- <br />39- 1 I ) <br />— �1111111111111tlIIIIIIIfIIIIIIII111111I[IIIIIIIIliiiii111111111111111111ililillllll111IIIItllli1111111111111111111111111111I11� <br />1 APPROVED APPROVED WITH CONDI-ON(S) DISAPPROVED 1 <br />(SEE ATTACHMENT WITH CONDITIONS) 11 <br />N I PLAN REVIEWERS NAME '� DATE 61 <br />�•T <br />--I11n11111inillli111 i Iillilulni�lu llullilulluniuilIII iuliuui11indimin II 11 uiltllulunnIIII <br />I <br />APPLICANT MUST PERFORM ALL WORK IN ACCCRDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF ) <br />I <br />SAN JOAQUIN COUNTY ?UBLIC HEALTH SERVICES. OWNER OR LICENSED AGENI'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT I:I j <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS P_RMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CAL:=ORNIA.' CONTRACTOR'S HIR` -NG OR SUBCONTRACTING SIGNA:VRE CERTIFIES THE FOLLOWING- <br />-I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, HALL EMPLOY PERSONS SUBJECT TO WORKER'S I <br />COMPENSATION LAWS OF CALI O IA.- <br />APPLICANT'S SIGNATURE: "' v TITL .1 2 <br />r <br />MEM <br />CA LIC X <br />PHONE X <br />PHONE <br />PHONE, <br />I1-1 ! A <br />WORK . C0" _ X <br />PHONE <br />B ILLING INFORMATION_ <br />Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond <br />permit payment coverage per tank. If the party designated below is different than the permit <br />applicant, e.g. property owner, the party must acknowledge this responsibility for the billing <br />by si nature and datebelow.bbeellow. � I /Vt�CNa L ess2 `� one numb er� <br />_ -/ <br />!T- <br />S ignature <br />r.H 23-0038 <br />CK <br />1 <br />