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�w- ENVIRONMEVTAL HEALTH DIVISION <br />^" APPLICATION FOR UN&OUND TANK RETROFIT, OR PIPING REPAIR PERM <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE., WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />_TANK RETROFIT %' PING REPAIR 'fEZW p'r <br />EPA SITE k PROJECT CONTACT 6 TELEPHONE k/�p <br />/-�J007 <br />FACILITY NAME PAO k .s <br />A {1� ` Z�9 S <br />C ADDRESS . i � e c ♦ �t�C"'S'�,�c.;� •� J�CM„TO �V t� <br />I � �y -C-t <br />:. CROSS STREET <br />I <br />T OWNS OPERATO I PHONE k <br />Y t-4 ^V IA C%_ I l I *%Ll rrf 7_eY4-Lf0- -A c - <br />OCONTRACTOR NAME_ _.R'_ �, '1 1 cc_` e /„ p "7 Ce I PHONE No <br />N CONTRACTOR ADDRESS& -F? �+O ` 4 , { j l `+ v��CA LLJI�C k ��� `-`•/ ZCLA'SS2 /�elo <br />R <br />A <br />T <br />0 <br />R <br />T <br />A <br />N <br />K <br />INSURERsI'1 �'_/1 't y p � n <br />1 <br />WORK.COMP. 1<S01 2 6 7 _ <br />OTHER INFORMATION <br />PHONE k <br />PHONE k � <br />Ililllillllllllllllillillllllll � <br />TANK ID k TANK SIZE <br />CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />_ <br />39- ) C <br />39- �41'� A52- <br />' <br />39- <br />I <br />9- <br />39- <br />_I <br />39- <br />39- <br />P I <br />L ROVED APPROVED WITH CONDITIONS) DISAPPROVED <br />APLPN REVIHWERS NAME SEE ATTACHMENT WITH CONDITIONS) a12151w <br />DATE111111 1 1 1 i t 111-11 <br />PLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF 1 <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 COMPENSATION LS OF CALIFORNIA."' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />'I CERTIFY THAT IN THE PBffr <br />WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER S <br />COMPENSATION LAWS <br />OF <br />IF A.• 7 <br />APPLICANT'S SIGNATURE: TITLE �r�a ,e DATE, 1 30--� <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 . �addr ss phone numberZ.cq-4e3-- B ZS 9 <br />Signatur <br />EH 23-0038 <br />1 <br />