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APPLICATION FOR UNDERGRO TANK RETROFIT,1 OR PIPING REPAIR PERMIT <br /> :':IIS PERMIT -EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT PIPING REPAIR <br /> EPA SITE # V /S PROJECT CONTACT 4 TELEPHONE # <br /> F FACILITY NAME v PHONE # e� t� Q".- <br /> A h v <br /> C I ADDRESS <br /> I � <br /> L I CROSS STREET I <br /> Z � � <br /> i <br /> T I OWNER/OPERATOR I PHONE I <br /> Y i I '�'i7 <br /> C j CONTRACTOR NAME PHONE # OCIJ/ l oq -+ pw I-�.�z' ' I <br /> 0 /r� <br /> N I CONTRACTOR R I CA LIC # V I CLASS2 <br /> VVV ''' iii Q/ [ <br /> R I INSURER LA, I WORK.COMP_$ — O <br /> a <br /> C I OTHER INFORMATION I I <br /> T <br /> 0 I I PHONE # <br /> L <br /> R � <br /> PHONE # <br /> —11111111111111111111111111111111 <br /> TANK ID # TT,Nc: SIZE CHEMICALS STORED CURRENTLY/PREVIOUSL'f DATE UST INSTALLED <br /> 1 39— 1 I I <br /> T I 39- t I I <br /> A I 39- I <br /> N I 39- t I I I <br /> K I 39- I I I <br /> i 39— 1 I I ! <br /> 39— t I I I <br /> --1111111111111111111111111111111111111111111111111)11111111111111111111111111111111111111111111111111111iIIIi111111111111111111I <br /> P �/ <br /> APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> (SEE ATTACHMENT WITH CONDITIONS) <br /> DATE <br /> N I PN REVIEWERS NAM <br /> LA <br /> —1111111111111111111 1!11111 III11 Ill illllllllliillllllliillll11111111111111111IIIIIII�I�titttat�llllllllillllilll <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF j <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 PEti:4IT 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 HIR:NG OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:I <br /> "I CERTIFY THAT IN THE PERr VCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, Z HALL EMPLOY PERSONS SUBJECT TO WORKER'S I <br /> COMPENSATION LAWS OF CALS 0 ZA.• I <br /> ' ,�,'1nJl '7 x <br /> APPLICANT'S SIGNATURE: 60iIIJ TITL / W1= Z v <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 signatu a and date below. <br /> � j <br /> ` <br /> address " phone number <br /> Signature <br /> EH 23-0038 <br /> 1 . <br />