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1+0-26-201 6=17AM FRSACRAMENTO EMC 9169252816 P.3 <br />Environmental Health Division <br />Application for UndcTraund Tank Retro t Or Piping Repair Permit <br />'this perrrdt expires 90 mays from the aapravat date, Cao not write In any shaded areas, Indicate permit type below: <br />Tank Retrofit Piping Repair <br />Applicant must peMar work in accordance with San 3oaquin County ordinance, state taws and rules and regulations of Son <br />Joaquin Cfb Pu C ServicEs. er Or ICCensecf agent's signature certifies the foilavuing; I certify that in performance of <br />the work for which I per is shat! not employ any person in such a maittter as tb become subjeti 1A/orlcas's <br />Compensation laws al nia �a is hiring ors txirtg signator$ certlfies the flowing: I certify that In the <br />p for whit iss^ed� Y afl empioy persons subject to W►orker's Compensataon i pf Cafifgmia. <br />Applicants <br />Billing &tformation: <br />Indicate the responsible party to be billed for adcWonal PHS_EHD staff 11me expended beyond permit payment coverage per tank. if <br />the party designated below is different that the permit *Mlcant, e.g. property owner, the party must acknowledge this responsibility <br />for the billing by signawre and date below. <br />Name: Saaramonto Equipmvent M . <br />2533 Cannie DdveF - Sacramento - Gly 95SIs 916-925-27X6 <br />Signature <br />Linda Stenger - Prmident <br />v:\ county \ san joaquih \ env \ forms \ permits \ repairs2 Wo #106706 <br />