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ENVIRONMENTAL HEALTH DIVISION <br />i APPLICATION FOR UND*ND TANK RETROFIT, TANK LINING, OR PIPING 0 I 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 I PROJECT CONTACT & TELEPHONE &re <br />F FACILITY NAM p NE <br />A <br />IADDRESS LAL <br />L CROSS STREET <br />I <br />TOWNER/OPERATOR PHONE <br />[1(9:�n <br />C CONTRACTOR NAME�� S PHONE # <br />0 146 1 3' <br />N CONTRACTOR ADDRESS l CA LIC ftA HA7 b ' CLASS _ L� <br />T LJ I W f�Az <br />R INSURER Con eaI WORK.COMP.» a a�'- 347--97 <br />Aej2 <br />C OTHER INFORMATION <br />T <br />0 PHONE <br />R <br />PHONE <br />111111l111lllllllllllltllilll! <br />39 - <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />T 39- I G C L� A S c� l—; ..�t \C% 1k Cl <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39- <br />1111 <br />P <br />L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />A,�$EE TACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAMEyy DATE Q 9% <br />1111111lII1111111l1111lI111111111111f1i11ltllllilillllll 1111111l11l11111111i 1111 1111 1111111111 ill ifilllilflll1111111111 <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 PERSCNS SUBJECT TO WORKER'S <br />CCMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: TITLE DATE <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 billing by signature and date below. <br />Name -X 1A o G L, 4 S <br />Mailing Address �y1 C_ I.A-� \A'Lu St, LraT \A 9"rJ <br />Day Phone Number <br />Y <br />Signature <br />EH 23-0038 <br />1 <br />