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+-- ' ENVIRONMENTAL HEALTH DIVISION <br /> ' i 1 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LIHING, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM-THS APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE*PERMIT TYPE BELOW: i <br /> ®TANK REPAIMETRO.FIT _TANK LINING PIPING-RC~ I <br /> EPA SITE 0 C I PROJECT CONTACT & TELEPHONE A <br /> A FACILITY NAME (L rt '"CRE 11 <br /> C ADDRESS Z3-715 <br /> I <br /> L CROSS STREET <br /> t <br /> T OWHEOPERATOR PHONE <br /> Y e <br /> C CONTRACTOR NAME PHCdtE # <br /> O <br /> H CONTRACTOR ADDRESS CA LIC # CLASS <br /> T <br /> R INSURER WOE;-COMP.I <br /> A <br /> C OTHER INFORMATION <br /> T <br /> O PHONE 9 <br /> R <br /> PHONE S <br /> TANK ID III iIIIiIIiIII TA (SIZE CHEMICALS ST 90 CURRENTLYIPREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39. <br /> 39- <br /> P 1111 <br /> L APPROVED APPROVED WITH CONOITION(S) DISAPPROVED <br /> A A CHMENT WITH ITIONS) / <br /> N PLAN REVIEWERS NAME DATE. (v" <br /> (II111II1111i111I11I 11 11111 i lI l 1 1 1 111111IIC 1 1 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCZ WITH SAN 40ACUIN COUNTY ORDINANCES, STATE LAWS, AND-RULES AND•REGULATIONS Of <br /> SAN 4OAQUtN COUNTY PUBLIC HEALTH SERVICES. C6NER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING.: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE 'WORK FOR WHICH THIS PSX9T 13 ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFCONIA-" CONTRACTCR'S HIRING OR SUBCONTRACTING SIGNATURE' CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE W= FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE DATE � ( ✓ <br /> -1 <br /> LLIHG INFORMATION: <br /> iicate the responsibte party to be bitted for additionat PHS-END staff time expended beycr4 permit payment coverage per tank. If the <br /> -ty designated betow is different than the peruit;appticant, e.g. property owner, the party must acknowledge this responsibitity for <br /> t bitting by signature and data below. <br /> i c ing Address <br /> e Phone NurseraU ) 6 2 "— <br /> ;nature LILL <br /> 23-0033 Jaw <br /> 1 <br />