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06/27/2001 13:57 209468,63 FIFTH FLOOR PAGE 02 <br /> .4 APPLMMON FOR UNDERGROUND TANK RETROFIT, OR PIPING REP?,IR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY zF=20 AfttAs- XNOXCATE PERMIT TYPE BELOWt <br /> R---MOFIT PIPING REPAIR <br /> EPA SITE 9 PROJECT CONTACT & TELMMSt # <br /> F FACILITY NAME C) PHONE # 0 q cl�?_3 0-3S-1 -1 <br /> A I i <br /> C ADDRESS /6 5'oo 4-c1c)i�. <br /> I <br /> t. I CHoss STREET -5 <br /> I <br /> T I OWNER/OPERATOR PHONE Ik <br /> 6 C —71 <br /> C I CONTRACTOR NAME —i R1 14t1V Oj� L.:?-Al V <br /> PHONE 4 <br /> N J CONTRACTOR ADDRESS )j ukl?ANK &-uO CA LIC 0 CLASS <br /> T 1 <br /> R j INSURER WORK'I CQMV.9 <br /> A <br /> C OTHER XN-rOR.MATTQN <br /> PRONE A <br /> P <br /> PHONE x <br /> TANX ID TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T 1 39- <br /> 39- <br /> 3.4- <br /> K 39- <br /> L 4—S'PROVED APPROVED WITH CONDITION($) OXSAPZRQrVZO <br /> A (M ATTACHMENT WITH CONDITIONS) <br /> N j PLAN REVIEWERS NAME DATE <br /> ---AIIIII III III HII III 1111111-111[if M-1111111 IIIIIIIII-ITI 11111 11111111111111111111111111111111111111111111111111111111t1111i If If I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUI14 LOUNty O?MxVAKCZ5, STATE LAWS, ANn putgs AND jtErULATxONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SZRVIC-.$. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING! *1 CERTIFY THAT IN <br /> THEE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. � SRA" NOT EMpLooy ANY PERSON IN SUCH A MANNER AS TO DECCME <br /> StMIECT TO WbAkEk,S tAw$ OF "IFOZW%A.- CONTRACTOR'S HIR:NG OR SUBCONTRAL-rTNZ SIGNATURE CPPTMPT= T= rOLLOWTNC: <br /> "I CERTIFY THAT IN THE PERPORKANCE Or THE WORK FOR WR THIS PtRX7T IS 15=, I- SHALL EMPLOY PERSONS SUBJECT To WORKER'S <br /> COMPENSATION LAWS OF CALIFORNXA." <br /> APPLICANT'S SIGNA-URE: ------- TITLE 1-Vj'11111&rjW1e4V DATE <br /> BILLING INFORMATION:' <br /> indicate the responsible party to he billed for additional PES-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 signature and date below. ,2'.-2,; vvVU1,29/111vir <br /> S <br /> Name-TRZAP/qaddress ~-1 / hone number <br /> Signature - <br /> ,22 <br /> 1 zjV7: <br /> 3H 23-0038 <br />