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APPLICATION FOR UNOE&D :'ANK RETROFIT, OR PIPING REPAIR PERMIT <br /> s <br /> :'3rS PERMIT EXPIRES 90 DAYS FRCM THE APPROV;:- DATE, DO NOT WRITE IN AA. SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> ,TANK R-=FIT PIPING REPAIR q <br /> EPA SITE # PROJECT CONTACT d. TELEPEiCNE # l <br /> c ` cACZLITY NAME "c: ) (J® PHONE # <br /> a /� J / <J <br /> DRESS <br /> I `317 ((,[ C.'(/ r(;'�i - <br /> Jja <br /> CROSS STREET <br /> Z � ' <br /> T OWNER/OPERATOR PHONE 9 <br /> C7 <br /> C CONTRACTOR NAME `'� / O ✓1 <br /> J' !/ PHONE <br /> N CONTRA R RES / f t' i CA LIC 3 CLASSOMA <br /> 6 <br /> R INS - WORC.COMP_# <br /> A � <br /> C OTHER INFORMATION <br /> T <br /> 0 I ' PHONE # <br /> R <br /> -- IllittltlllllttIfill 1111111111[ 1 PHONE 3 i <br /> TANK ID # T;L'- SIZE 11 CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 1 39 1 I 1 E <br /> T 1 39- 1 1 <br /> A l 39- 1 <br /> N I 39- 1 I <br /> K 1 39- 1 I I <br /> 1 39- <br /> 1 39- 1 <br /> — �II111111tlEitl1111t[1111IIIIItillIIIIIIll1111IIIIII111111111111t1111[Itllittllil!!lIIEIIIIIEIlttl111I1111111t11tttilllltlllll� <br /> 1 APPROVED _ APPROVED WITH CONDIT—ON(S) DISAPPROVED 4 <br /> (SEE ATTAC9A9ENT WITH CONDITIONS) 1 <br /> .1i 1 PLAN REVIEWERS NAME - DATE ! <br /> —11IIII 11111111IfIIII t11I11Illltlllttlllllttttllllllllitlllttlllllltlilltllt1t11lIllilllitllllllt111111tltttilfill IIIIIIllltllII <br /> A??LICANT MUST PERFORM ALL WORK IN ACCCRDANCE WITH SAN JOAQUIN COUNT! ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF j <br /> >'AN JOAQUIN COUNTY PUBLIC HEAL--I SERVICES. OWNER OR LICENSED AGENr'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN � <br /> TS"3PER EORMANCE OF THE WORK FOP,riiFiICH THIS ?ER4IT IS ISSUED, I SMALL NOT EMPLOY ANY PERSON IN SUCH A WANNER AS TO BECOME" <br /> SUBJECT TO WORKER'S COMPENSATION¢LAWS OF CAL:=ORNIA_' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING. <br /> 'I CERTIFY TH-T INTHE PERF VALE OF E WGRS FOR WHICH THIS PERMIT IS ZSSU I SHALL EMPLOY PERSONS SUBJECT TO WORK'ER'S <br /> COMPENSATION :.AWS OF CALZFO ZA,,.!' <br /> APPLICANT'S SIGNATURE: <br /> +i-TrL r <br /> B iLLING 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 gnature and date below. / <br /> N '(G/ ddress �[� / one number /(� <br /> Signature <br /> EH 23-0038 <br /> 1 <br />