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10-23-1998 11:51AM FROM P.2 <br />q '> - + . ' 0 ENVIRONMENTAL HEAL --i DIVISION <br />"PLICATI0N FOR UNDERGROUND TANK RETROFIT, or, PIPING REPAIR PERMIT <br />F <br />A <br />C <br />I <br />L <br />1 <br />T <br />Y <br />THIS PERMIT EXPIRES 90 DAY$ FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />-X-TANX RETROFIT PIPING REPAIR <br />EPA SZTE µ PROJECT CONTACT £ TELEPHONE ik <br />FACILITY NAME 1 y- a l l C. C), tt Ll a --I C ' PHONE 0 '�Q� - LA <br />y <br />ADDRESS�� C�—t L.�c ��- �� l c���Sd-©c k���, 0- A cis - <br />CROSS STREET p� ` A, li <br />OWNER/OPERATORI PHONE R <br />(\--l c �lA r, 0 i( C c� r) e( n 15 3c) 9 815- O 4n 1 <br />CONTRACTOR NAME <br />& 1 ; +- �j GG LL PHONE A c� -{� 1 - 43 3 7 <br />CONTRACTOR ADDRESS 15(� Ll30t rn JT 1 l� I CA LIC S AHA 7- lr L 7 (y i CLASS A H Iq <br />INSURER V, r 0 1-1 ft -L f 1.1- -CA S 3S`13 cI I f WORK.COMP.a �� _�� `-17—��k <br />jam, ■ - - , <br />o=R INPORMATION <br />G -D-)-si,!Ca <br />I I PHONE C I <br />I PHONE R <br />TANK <br />--IIII11tiIt111111111111111, <br />TANK IDC TAM SIlE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />1 39_ <br />T 1 39- I I <br />A l 39- I i <br />N 1 39- <br />X l 39- I I <br />1 39- <br />111 11 <br />P 111111111111111 I 1IIIIII11111111111111111111111111i11111111 Il Iiilillllillillt11i11111111i11 <br />L I APPROVED APPROVED WTTR CONDITION(£) DISAPPROVED <br />A 1 (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAMIZ DATE <br />----1111 I 1111111111111111111 HI1 111111111111111111111tI11IIIIIIilII1111111111111111111iI1111111111111111111 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN =AQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. 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 COMDENSATION LA6/S OFCALORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATOR£ CTRTIFIES THE FOLLOWING! <br />-I CERTIFY THAT IN THE PERFORMANCE OF THEX FOR WHICH THIS PEMMIT IS ISSUED, I SRALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIPORNIA.- , A /7 - <br />APPLICANT'S SIGNATURE: <br />BILLING <br />TITLE i• 6'�) fU t Q (�DATE 1 �'� 1 t( <br />Indicate the responsible party to be billed for additional PAS -£FID 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 � CNS address phone number <br />Signature <br />BE 23-0038 <br />Z <br />