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• <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3R0 FLOOR <br />STOCKTON, CA 95202 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />4 <br />i <br />APR 14 2003 <br />$VIRONMENT HEAL <br />PERMIT/SERVICES <br />TI ]IS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERK IT TYPE BELOW: <br />._--_TANK RETROFIT X PIPING REPAIR/RETROFIT ----UNDER DISPENSER CONTAINMENT REPAIR/RET+ OFIT <br />+---------------------------------- .- ------------------------------- <br />I I EPA SITE # ( PROJECT CONTACT k TELEPHONE # <br />1(1(1 ________-_.._--__.._`/-______�L.'!__CC!___=_--_--_-_ _�_�__2u__7____-_--_.._'_-_____ <br />F FACILITY NAME °_;1� <br />5"'__A+----- <br />I ADDRESS'77 <br />�\/J/--/sza�--y <br />-^__-_- <br />-__---+ ------- <br />L 1 CROSS STREET <br />- <br />�I <br />1 �.+------------------------------------------ .____. _________________ <br />T 1 OWNER/OPERApa._ I PHONE 9 <br />Y <br />-------------- F11 -- 6-wwl -----------------.-{---._t <br />C CONTRACTOR NAME ! <br />___-___ <br />( N I CONTRACTOR ADDRESS ( CA LIC # I CLASSI <br />T+------------...'------------------------------------ <br />R INSURER ( WORK.COMP.# <br />IA ---------------------------------- ------------------------ - ------------------------+- <br />( C ( OTHER INFORMATION I <br />------------ <br />1 -------- <br />0 I I PHONE # I <br />I ----- ---------------------- ------------- -- - -----' --------.'t I <br />R +-----'-- - _______- ----------- +---------------------- -------- <br />( PHONE # <br />+ -------------------------------- -- ------------------------------------------- <br />-= <br />TANK ID # I TANK SIZE I CHEM; S STORED CURRENTLY/ PREVIOUSLY I DATE UST IALLED <br />I I 39- <br />'I' 139- <br />T A 139 <br />I N 1 39- I <br />i K 1 39" 1 I I I <br />139 I I I <br />I <br />139- <br />+___illlllllilllllllllllllllllllllllllllllllllll'111111'111P IIIIII1111111111111111111111111111111111111111111111 H IH IIE IIIIIIIII <br />IPI / I <br />I C I r APPROVED V APPROVED WITH CONDITION (S) DISAPPROVED i 1 <br />I A ! �^ a EI•. 7 ' CHMFNT WITH CONDITIONS) <br />N f PLAN REVIEWERS NAME___ V_V • �/'v \/I/� DATE ��W 1 <br />a <br />+--Illllllllll111111f111111f11t11111lIIIIIIIIIIIII1111111111111111111111111111111II11111111111111III11111111111111111111`IIIIIIIII <br />' ' I <br />I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIO[' OF I <br />1 SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I IRRTIPY I I THAT IN THE <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO I <br />1 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFI§ THE I <br />FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUB'; CT TO I I WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />I <br />I <br />APPLICANT'S SIGNATURE: ell_ TITLE _. DATE <br />I <br />.�_. ... ..........._--...---------------------------------------------------------------------------------- --------- <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyc,nd <br />coverage per tank. If the party designated below is different than the permit applicant, ti.g <br />the party must acknowledge this responsibility for the billing by signature and date belowltl <br />f <br />Name---- -.._._.._. --- ---- ----- Address---- ---------- — -- Phone — <br />1 1 <br />r <br />r <br />permit payment <br />property owner, <br />