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APPLICATION FOR UND OUND TANK RETROFIT, TANK LINING, OR PIPING AIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE A ROVAL DATE. DO NOT WRITE IN ANY SHADED ARM. INDICATE PERMIT TYPE BELOW: <br />TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br />EPA SITE 9 PROJECT CONTACT & TELEPHONE a <br />AFACILITY NAME , PHONE ® A e <br />C ADDRESS a Ca C9 <br />I1+2 ,Qt A QCX e <br />L CROSS STREET <br />I <br />T OWNER R ( PHONE <br />Mp„ # <br />OC CONTRACTOR NAME 11-7—C, <br />® 72 Q C C% h e s PHONE " ® / 3 <br />N CONTRACTOR ADDRESS r I. It' a CA LIC # G CLASS Co <br />T WtfA <br />A INSURER i)C0 �/ p � WORK.COMP.1 - � O ^ 3 « <br />!, �` C7 <br />C OTHER INFORMATION <br />T ® . O cp <br />t <br />0 PHONE <br />R # ® �� j' fC3> Z <br />PHONE <br />tlllt!!!Iltttlllillifililliltl • <br />39 - <br />TANK ID T TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED <br />T 39- <br />A 39- ` <br />N 39- 11 <br />K 39- <br />39- <br />39- <br />P fill111111111 if III fill] <br />L PPROV 0 APPROVED WITH CONDITION(S) DISAPPROVED <br />A ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NA DATE <br />(llllilllilltlllllllll 1111 111 IltJllttl! 11!11 11111! 1111111111 !!!illtl! 11 tI111111I11t1 1 ill 11111111111111!111111 <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: Lr�%% f , <br />BILLING INFORMATION: / <br />Indicate the responsible party to be billed for additional PHS-EHD 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 bilt-ing by signature and date below. - <br />Name <br />Mailing Address <br />Day Phone Number ( ) <br />Signature <br />E -H 23-0038 /zl - C�l <br />�& Le"'e, ke, �e) �- /" <br />1 <br />