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i 3,5/27/2001 13:57 2094633 FIFTH FLOOR PAGE 02 <br /> APPLICATION FOR MMERGP45MM TANK RETROFIT, OR PIPING REPAIR PERMIT ~Cr ^ <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SNRDED ARSAS. INDICATE PER�+/1t/')�jPE B-ZfAWs <br /> W�TANK MSTROFIT PIPING REPAIR •(� <br /> SPA SITS k PROJECT C== & TELF:PgCNE k <br /> , <br /> FA FACILITY NAME _l L)I e_5rop .Ji '7 1 ' PHONE #&q 90-6 <br /> � U( _ . 952-05 <br /> 90-w <br /> k, <br /> rADDRFSs <br /> JO,D S. 00ye16VIE <br /> L I CROSS STREET � <br /> I <br /> I <br /> T I owNER/oPP_RATOR &VI/CS7DP MAr2�Ei S I Paor� k __ <br /> - 1 <br /> C I CONTRACTOR NAME 7-R/Au&Lf EiNI V I AWMI N C-AMAL IMC . PRONE a <br /> ° '2 S�S u�2B"kL v <br /> N I CONTRACTOR ADDRESS I CA LIC G I CLASS I <br /> T ,BueB'%rky <br /> R j INSURER I WORK.COMF.k <br /> A <br /> C OTHER INFORMATION I <br /> T <br /> O I I PHONE 3 <br /> P <br /> PHONE k <br /> –111i11111iITANK lzDi>I11111111111� TANK SIZE CBEMIC.IIS STORED CIIRRSNTLY/PREVIOUSLY DATE UST I115TALLM � <br /> T j 39- 1 I <br /> A j 39- i I 1 I <br /> N 1 39- I I I I <br /> K j 39- I I <br /> 1 S9- I 1 <br /> -�ililjlli11111111i1i1i111l111lIIIliIlI11111111jlllllllllllllllllillll Il 1 1 jlillllt111 11 1 1 I l ! 1 l l 11 ' <br /> L 1 APPROVED APPROVED KITH CONDITZON(S) DISR>'FROVaD 1 <br /> A I ( ATTACIMCNT WITH CONDITIONS) -- <br /> -41111111111111111111 <br /> 1 <br /> —I111111111111111111HIM1111 II 111 1 l i I Illillillllil1111111111111III1IIIII'll111111i�ll�1LIIIIIIIifI <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY OFLOrNANCES, STATE LAWS, AND ROLES AND REG=J ATXONS OF <br /> SAA JOAQUIN COUNTY ?UBL:C HEALTV SZRVIGS. °WNZR OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN <br /> THE PERFORMANCE OF HE WORK FOR WHICH TRIS PERMIT IS ISSUED, Z SkALL NOT EM-pLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> StmJECT TO WOJUM-S COM?ENSATXON LAWS OF CN.IFQWZA." CONTRACTOR-S HIR_VG OR SUBCONTaACTING SIGNATURE CERTIFIES THE £OLLOwING:I <br /> I CERTIFY TKAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PS MIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S 1 <br /> COMPENSATION LAWS O£ CALIFOANXA. <br /> APPLICANT'S SIGNATURE: / G.J TITLE .4UDI/hit5,,- 4-r01L DATE C I aI <br /> BILLING 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 signature and date below. <br /> Name address phone number <br /> Signature <br /> EH 23-0038 <br /> 1 - <br />