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S-26-1998 1 :d8PM FROM P_ 2 , <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNOERG2CUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL <br /> DATE.. DO NOT WHITE 1N ANT SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> �T EPAi RE}'ROFI7TRUING LtRTAG PIPING REPAIR <br /> EPA SITE S Gds PROJECT CONTACT L TELEPHONE 0 <br /> F FACILITY MAKE LES- <br /> I ADDRESS \ 53(E <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE s <br /> C CONTRACTOR NAND PHONE 0 '� T <br /> N CONTACTOR ADDRESS <br /> T a s CA LIC s 4 CLASS �o' <br /> A INSURER _ WORK.=1P.;N <br /> r1'7 5 <br /> C OTHER INFORMATIONN <br /> I <br /> 0 PHONE s <br /> R <br /> ii!!tl111iitIlllltii111tI1lItI PHONE # <br /> 34- TANK ID S TANK SIZE CHEMICALS STORED LT/PREVIOUSLY DATE UST INSTALLED <br /> _ <br /> T 39- / [ <br /> N 39- _ <br /> y� <br /> K 39- <br /> 39- <br /> 39- <br /> iii! <br /> P 10 <br /> ' ✓�® r <br /> LAPPROVED IWITH IT OHCS) DI <br /> A E ATT T WITH CONDITIONS) <br /> N PLAN REVIEWERS N DATE <br /> fill i111]11[if fill ii 11I TWI It1111111KIIIIIIIIIIIIIIIIII 1111011111mill111111 ill <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JQI COUNTY ORDINANCES, STATE LAMS, AND RULES AND REGULATIONS OF <br /> SAN JOAGUIN COUNTY CLIC HEALTH SERVICES. OWNER OR LIC:NSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PeRFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL HOT CLOY ANY PERSON IN SUCH A MANNER AS To BECO E <br /> SUBJECT TO 'S COMPENSATION LAWS OF CALIFORNIA." CON 'S HIRING OR USCMITRACTtXG SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PMIT IS ISSUED, I SHALL ENPLay PERSONS SUBJECT TO WORKER-S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLIC.AAT-S SIGNATURE: ® „ TITLE a Ck 6 DATE I ( /Co <br /> BILLING iNFORMATION: <br /> Indicate the responsible party to be bitted for aiIditiamt PHS-£HD staff time ex it t Cover r tw*. If the <br /> party designatedAe Pew Pay <br /> below �a different there the it apptiCat e.g. property owner, the party mugt aeftrmtedge this respibiliry for <br /> the billing by siV*ture act date below. <br /> NameLa l - L LIII '5Y-,)-1 L U�L !,�QL <br /> Mailing Address <br /> DaY Rhaf4 Rtm ber ) <br /> Signature <br /> .H 23-0038 <br />