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ENVIRONMEN-TAL HEALTH DIVISION <br /> APPLICATION FOR UNDIUND TANK RETROFIT, TANK LINING, OR PIPING <br /> 10IR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br /> EPA SITE # CAL OQ o 6 q S q Z PROJECT CONTACT & TELEPHONE # /�� ��V�L f ��d _ f-7 •SGi(J <br /> F FACILITY NAME 1, 4 PHONE # �d <br /> A <br /> C ADDRESS <br /> L CROSS STREET ]Ac-k 7dNe RdAj <br /> I ,v <br /> T OWNER/OPERATOR PHONE # �I <br /> Yc. <br /> CG I CONTRACTOR NAME ���[� .L PHONE # d c1— ,IIG �~ a <br /> O <br /> N CONTRACTOR ADDRESS •JS jj,' y;�q.,-� . fc �c� yfu CA LIC # �'�LIQ 76 CLASS C <br /> T <br /> R INSURERWORK.COMP.# e <br /> A �r3e � Z Ai /wa, ;s iC7s' �i'rvtr .�. x#� ZjO �C�N��42 .229C�93�f7- 9 <br /> C OTHER INFORMATION <br /> T t A ' <br /> R �La T e .LIL gJ�i'E� d2J' ° ' ' PHONE # �� — 6 —!a JJ <br /> PHONE # <br /> 111111111111111111111111111111 <br /> TANK ID # TANK SIZE CHEMICALS STORED CU ENTLY/PREVIOUSLY DATE UST INSTALLED <br /> T 39- <br /> A 39- c6�d`'' <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L AP ROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAM DATE rJ <br /> I111111l111111111111i11i! 1 !il 1111 1 1111111 ! !1111 Ill 111 1 I I ill illililil I !1!1 i 1111 illliltll <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 WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE iic�ecTd•?t �t"�✓. /`tlfi9iE'fDATE <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-END staff time expended beyond permit payment coverage per tank. If the <br /> party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br /> the bi l ling by signature and <br /> date below... <br /> Nameo,.-.t,, lylaL- 4 s n TIN4 " /V ' � Al2'e7O <br /> c 6� 1', <br /> Mailing Address �(). i�c,X S7'/4" Faamd w� , ��7 jf S 7 <br /> Day Phone Number ( S/Gl ) GS" 7- .l <br /> Signature <br /> EH 23-0038 <br /> 1 <br />