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. . S' <br />16 <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGO TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS <br />TANK RETROFIT PIPING REPAIR <br />INDICATE PERMIT TYPE BELOW: <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 />J <br />Name GINZ( w _ jE,.4,£4--addresss2,7 N•- PA'2 kv, -I, hone numbe ��� <br />Signature�----- <br />EH 23-0038 <br />01 <br />D �f���li <br />FEB 1 6 2001 <br />ENVIRONMENT HEALTH <br />PERS/SIT/SERVICES <br />EPA SITE # PROJECT CONTACT & TELEPHONE # <br />F <br />PHONE # Z(j�j 70/_ — � 3 <br />FACILITY NAME 74, C &cj <br />I lG� 7� <br />C <br />ADDRESS Z:3-7,5 -rQ-A(-q J� tv -8 c <br />II <br />CROSS STREET -T—Q_jN'4-\' Cy-\ 9,573-7(6 <br />` <br />Y <br />i OWNER/OPERATOR PHONE # <br />C <br />CONTRACTOR NAME LL S ���. �. PHONE # S�' L� 41L��1 .7,3e <br />0 <br />N <br />CONTRACTOR CLASS <br />ADDRESS �Z-7p- �ba(Z kv t ,� �� CA LI( / <br />T <br />R <br />I INSURER I WORK.COMP.# <br />C <br />OTHER INFORMATION <br />0 <br />PHONE # <br />R <br />PHONE # <br />TANK ID # TANK SIZE CHEMICALS STOnnggEED LY/PREVIOUSLY DATE UST INSTALLED I <br />TANK <br />T <br />39- I I <br />A <br />39- <br />N <br />39- <br />K <br />I 39- <br />39 <br />1111111111111111111111111111 ��������������������� IlillllllllllliIllililllllllllillilllllllllillllllllllllllllllllililllli� <br />P <br />L ' APPROV)R�' APPROVED WITH CONDITION(S) DISAPPROVED <br />A ' (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME' DATE <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN 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 COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:! <br />"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORK --R'S ! <br />COMPENSATION LAWS OF CALIFORNIA." <br />/ <br />L-,- TITLE Sre-y L'� �cLg DATE 24-o <br />APPLICANT'S SIGNATURE: �!"^'( <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 />J <br />Name GINZ( w _ jE,.4,£4--addresss2,7 N•- PA'2 kv, -I, hone numbe ��� <br />Signature�----- <br />EH 23-0038 <br />01 <br />D �f���li <br />FEB 1 6 2001 <br />ENVIRONMENT HEALTH <br />PERS/SIT/SERVICES <br />