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8-25-1998 3:58PM FROM <br />ENVIRONMENTAL HEALTH DIVISION C'- r - <br />APPLICATION FOR UNDERGROUND TANK RCTROrZT, OR PIPING REPAIR PZRNr- <br />THIS VMbUT EXPIRES 90 DAYS FROM THE APPROVAL DATE DO Mar. WRI23 IN ANY Sy-aZ= AREAS. IND CAT8!P)3RNrr-T1f PE BELOW <br />P I S LER V I Q; t <br />TANK HIDING. RSPAIR <br />EPA SITE 4 PROJECT C ()0 <br />CONTACT' # <br />F FACILITY NAME tE� rHWCT'r' PHONE 01) 1.744 <br />A �-- zu&5 IAID�L* <br />C ADDRESS <br />I NV*, <br />CROSS STREET <br />-r OWNER/OPERATOR PHO <br />6ft-ir-c� AV # % 4 -z - <br />Y (01vab 10 <br />1--r I PHONE P (fl 14jr) <br />c CONTRACTOR NAME ",ft4 4Dr4*TNe-Tjb-1 I <br />0 Qm!� -- 0 V).A7- 6 <br />CONTRACTOR ADDRESS 0-14-1 Q0FA" j CA LIC X &1;3 CLASS <br />08 <br />R qSURsR <br />WORK.COKP.# <br />:' <br />A tm� <br />C OTHIM INFORMATION <br />T <br />PHONE 6 <br />0 <br />PRONE 4 <br />—H i i 11111111 TANK ID a TANK SIZE CHERICALS SrgRED CU4RENTLY/ P SLY DATE INSTXZED <br />T I 39- 2— -7 1 Itt Wo <br />A j 39-- -tA:* <br />14 I 39- <br />K 1 39- <br />29- <br />39 - <br />If IIIII IIH Ili fill I I III I if liff-I I I I III I I n it I III I I III III I I I I fill I III I I I I I I <br />L APPROVED APPROVED WITH MMITION(S) DISAPPROVED <br />SEE A-IrACHMENT xr-.A CONDITIONS) DATE <br />N PLAN REVIEWERS -JAM '6-'ef'c' <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN ORDINANCES. S -A -.S LAWS, APO RULSS AND REGULATIONS OF <br />,AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES_ OWNER OR LICCNSCD AGr-N1r*S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 'r. -AT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL NOT CKPLOY ANY PERSON IN SUCH A *4ANNER AS To BECCME <br />SUBJECT To WORKER,S COMPENSATION t.AWS 07 CALIFORNIA.' CONTRACTOR'S HIRIM OR SU=W-'RAC--- NG S7GXATaRE C3RTIFISS Trek' I <br />*1 CZRTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PEE2%rT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT 70 <br />COMPENSATION :AWS OF CALIFORVZA.* <br />akfTAO <br />APPLICANT'S SIGNATURE. <br />ILLING tNFORMATION: <br />ndicate the responsible party to be billed for additional PHS -EI -M staff time <br />xpended beyond permit payment coverage per tank. If the party designated <br />elow is different than the permit applicant, e.g- property owner, the party <br />ust acknowledge this responsibility- for the billing by signature and date <br />elow. jj�j A. M&Q0NEU-- <br />ame M41644 ro"vtrilO�-;ddress-15—w—r->-+hone number <br />C-�b1i 1fu�� tts�o <br />ignature <br />-rf-,rr-,i5'2-5 CGSc;,P- AT <br />H 23-0038 <br />MAX I e Id < <br />/'VyN <br />oil <br />H <br />