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APPLICATION FOR UN ROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />a <br />;--;oiIT EXPIRES 90 DAYS PROM PPROVAL DATE, DO NOT WRITE IN ANY SHADED ARE I��ICATE PERHI' TYPE BELOW <br />_TANK RETROFIT -IL PIPING REPAIR <br />A/ -PA >.'E ��AL 0000 ys9 1!;7 �J�J I PROJECT CONTACT i TELEPHONE 13 E f:P VAJ RIPCti r10 • 4Q}- gS00 <br />(!- FAC: -:TY NAME &j L)114 SroP X 1q PHC\_ 1 -09k:,:) RESS �Z}Z uf�$'r („AI''m STOCICTO&A CA 9SZOcj <br />-:CSiSTREET �AW►NAF.R'C'QWp( �nL.tvF— <br />'.NEi CPEPA70R I PHC\= 1 <br />Q U IK- STOP M A 2IGK�Irf , !V1I c I S'ro - 6 S' I- T So 0 <br />CCN..'7,CIOR NAMEPHC\= as- L <br />U%A,LTo4 F-#4 eAFF- rtlNf. 1wt C 9i _ 3,43 _ <br />ADDRESS CALICO M I CLASS <br />P 0 aox io:r W SA4,ro C� 61 Z3 ¢ A . B . HA2. <br />.�5_'R_k ST1'irTiL <br />COMP ir4 S�,-/� F:'/U A,V I WC%'<. COMP.p '3 i3 - L/s� 2'} OO - <br />C0mrh-C..T rYiI CW Arg-t-LVAi.1 <br />.r' 0 4 <br />i <br />I PHC\c p <br />—iIIIIIIIIIIIIIIIIII�III��������I <br />"AHK ID t TANK SIZE CHEMICALS STORED CURREN":'!/PREVIOUSL'! DATE VST <br />I I of 000 I Rt C. U N L y't I I- t6 - Tr <br />- I ,s• L I /0,_000 I rl,vi vNL <br />;;. 1 I P. 000 I P,%ifV% UML <br />I ;s• J i I <br />--I111111111111111111111 VIII I II I II I I I III IIIIIIIIIIIIIIIIIIII <br />AP,,PROVEDPP <br />PROVED WITH CONDITION(S) DISAPPROVED I <br />% 3 (S ATTACHMENT WITH CONDITIONS) <br />?Lr,v REVIEWERS NAMEE <br />—iIIIIIIIIIIIIIIIIIIIIIII I I I i IIIIIIIII II I IIIIIIIIIIIIIIII <br />.:PP':C'As7 41 -IST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATICNS :. <br />.;,, _ •^_:N COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES FOLLOWING. 'I CERTIFY -LAT :S <br />-=ERFOR.MANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON :N SUCH A YAYNER AS TO 9ECCME <br />_ _ECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACT'NG SIGNATURE C°RTIFIES THE=CLL7u:NG <br />7tAT :N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EM7_OY PERSONS SUBJECT TO WORKER i <br />=;rPESSA':CN ;.AWS OF CALIFORNIA.' / I <br />S >:ONATURE: TITLE -P^" DATE 0 L 2 G I I <br />I cW h tit- W A L T` Q q IAJ A c. T'0 ,( a •c (...r B � . , � r, L <br />BILLING INFORMATION: <br />IndiCa:Y the respedsible party to be billed for additional PHS-EHO Ytaff time expanded beyond <br />permit payment Coverage per tank, if the pRrty designated bolow la ditttrant than the parm;t <br />applicant, a,g. property owner, the party must acknowledge thin responsibility for the billing <br />by Bign,acure and dAto below. <br />Name i`Aoca d d r e a a yS67 LA/t'�:'��^,ra phone number. J010-dyS'-ZZ?S <br />S 1 gn a t u r e �%f�.•--�-�:�.. ,• ; l c �� /?�i�• � k uF'�.r,� �� r. <br />EH <br />APP 0 4 2001 <br />ENVIRONMENTAL HEALTH <br />1 PERMIT/SERVICES <br />