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' 1 <br /> AUG 2 3 2016 <br /> 304 East Weber Avenue,Third Floor,Stockton,California 95202 w � <br /> Telephone: (2 09)468-3420 Fax: (209)468-3433 <br /> 33 <br /> APPUCATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REP'AIR.PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW; <br /> E]TANK RETROFrr IDPIPING REPAtRIRETR0 T OUDCREPAIRMETROM <br /> FC EPA Site Project ContactTelephone# <br /> P ,. Name L Addresss <br /> a <br /> IGrossSteel <br /> T <br /> Y ownerfoperBtDr Phone# <br /> C Contractor(dame p <br /> T Contractor Address e / CA Lic# V i-q , . <br /> Rinsurer Work Comp� "` -� <br /> A <br /> T ICC T 'c iaWs tdu C� ration e 6 <br /> ICG Installers Cern N e <br /> Tank ID# Tank Size Chemicals Date UST InstwW <br /> Currently/PreAously <br /> T <br /> A <br /> 1 <br /> P ElApproved 19Approved with Conditions Dojsappmvw <br /> L (See Attachment With Conditions) <br /> A <br /> a N Plan ReviewersName Date / t® <br /> APPLICANT MUST PERFORM ALL RK IN AC Z E YNTH SAN JOAQUtN TY ORDINANCES STATE LAM.AND RULES REGULATIONS OF SRN <br /> JOAQUIN ENVI ENTAL HEALTH ER AGENTS SIGNATURE CERTIFIES THE FOLLOWING: '1 FY THAT IN <br /> THE GE C)F THE K FtN2 CH THIS PER I7 IS ISSUED,I&k4AI t NOT LOY ANY ON IN SUCH A AS TO BE CT TO <br /> S COMPENSATION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FO 1CERTIFY <br /> THAT IN THE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKEWS COMPENSATIONLA <br /> OF CALIFORNIA." <br /> fiAPP1=ft —-------- <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tark If <br /> the party designated below is different than the permit applicant, e.g, property owner, the must acknowledge this <br /> responsibift for the billing by signature and date below. <br /> E TITLE ✓ PHONE# <br /> ADDRESS <br /> SI TURF <br /> EH (re 81 <br /> 1 <br />