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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDEOUND TANK RETROFIT, TANK LINING, OR PIPING OIR 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 # PROJECT CONTACT & TELEPHONE # 7 <br /> F FACILITY NAME PHONE # / .. <br /> A (o <br /> IADDRESS 17.11 ® ,/ <br /> L CROSS STREET l Y <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y <br /> OC CONTRACTOR NAME <br /> 91� PHONE #.2 ® - b -3 <br /> N CONTRACTOR ADDRESS 3 eCA LIC 06 D CLASS C/ <br /> T <br /> R INSURER 6 ® 23 e 4 C WORK.COMP.# C �®U 4j7_ Q <br /> COTHER INFORMATION <br /> I <br /> 0 PHONE # <br /> PHONE # <br /> R <br /> F <br /> flllllltlt11111t1t11 <br /> 39- <br /> TANK IO # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> 1111 fill I I I iiiiiiiiiiiiiiiiiiiiiillifillifilI IIIIIIIIiIIINIIIIIIIIII 111111171 <br /> P , <br /> L APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A (SE P ACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME -d- DATE <br /> 1111111111111111111111 111 I 1 I III11111111i Iffl f s I I1 fl It tf ttltt! fU fllffflff I fl 1f1 fill i <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULE 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 PERFORMAN 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 <br /> ALIFORNIA °APPLICANT'S SIGNATURE: TITLE �.l� �ATE 9 T <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 <br /> Mailing Address <br /> Oay Phone Numb r f ) <br /> Signature <br /> 0 & <br /> EH 23-0038 <br /> 1 <br />