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06/17/2005 08:30 2094683431 EHD PAGE 03 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3i1D FLOOR <br />STOCKTON, CA 95202 <br />APPLICATION FOR UNDERGROUNU TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHAPED AREAS. INDICATE PERMTr TYPE BELOW: <br />_TANK RETROFIT _PIPING REPAIRIRETROFIT _UNDER DISPENSER CONTAINMUNT REPAIRIRETROPIT G V/I(r �Pv" <br />1 SPA SITfi # Z;4G-_ PROJECT CONTA& TBLEPHONE #^--��/✓� -�Q- j–_)k b <br />I <br />A +-FACILITY 1QAMfi �% A -1 -- <br />l___ -.N. ---------------.ADDRESS ----------- --- <br />- N <br />L1 CROSS STREET — -- — --=I-------------------------------------------------- <br />-'--------------------------- '--"---------- ---- — — — — ----- --' <br />= y-----------------------� yo,5'�oG y� <br />T I OWNSR/OPERATOR PHONE d <br />Y�&,+� --------------------------------------- <br />7 <br />--- -- ---- j-------------------+yy-�-p}-��-�---- -- f--/- ] (j---��-jj----/y <br />i C ; =TRACTOR NAME :v_./...-.�� __{�,�N_JlONE <br />pT I CONTSiACTOR ADDRESS �J � / [(� , ; CA LIC # � Q �/----C�'s/�-- — <br />R 1 INSURER'_'{ %�lP •�U s- ,++ccww++„III�� ,=---------------- <br />A;WxORK_ii�YY--MAS#r � 7�s..L� <br />/se-- — ....---_------------- <br />1 <br />C ; OTHER INFORMATION /T <br />O*----------------:..--------------------....------------------ ...---------------+-_ <br />PHONE #?aC--f- -T-! <br />R +------------------------------------------------------------------------------------a---^---- <br />_ <br />PHONE # <br />i ------------------------------------------- <br />TANK ID # TANK SIZE CHSMICRLS TORRD �7I <br />CURRENTLY/PRHOUSLY I DAVUST INSTALLED ; <br />; <br />A ; 39-� <br />N 39- <br />01 <br />K 39- <br />3B- ; <br />39- ' <br />+--- iriirr, iri irir.............. ;liri it ii <br />�. irrirr. irr i,i, iris it ri..r rl it , <br />P 1 i <br />_ pA �n APPROVED WITH COL�fJ7GTxON (S) DISAPPRwsa 612,610. <br />II <br />1 A ( MINT WITH CONDITIONS) /„ � D <br />1 N ALAN REVIEWERS SCAMS DATE r"rYYUUU <br />ilr rlli�i r�iill. ;111r ';;'i;r rr';i .. <br />�i;i;i;; i; iriir;;li;'�.i ,i irir i i;r ii .r. i riiiiiiri r it ..lir„ ii,;;li irrrii r. <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE wITS SAN JOAQUIN COUNTY ORDXNANCEE, STATE LAWS, AND RULES AND R89ULATIONS OF <br />SAN JOAQUIN COUNTY, E MAONMENTAL HEALTk DEPARTMENT, OWNER OR LlcaaSBD AGENT'S SIGNATURE CERTIFIES THE FOLLOWM-' "I CERTIFY <br />TFrnT IN THE PERFORMnNCE OF TRE WORK VQR WHICH TH%S PERMIT IS ISSUED, x SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER .0 TO <br />BECOME SUBJECT TO WQRAER'S COMPENSATION LAWS OF CAS.IFORNIA.- CON'TRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I <br />FOLLOW%NO! "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, i SHALL EMPLOY PERSONS 1.U3JECT TO I <br />I <br />WORKER'S COMPTHSATION SAWS OF CALIFORNIA,' _ <br />�Lg /�✓=i , r� DATE <br />APPLICANT'S SIGNATURE:L(%��y -- <br />+----------------------------------------------------- -------------------------+ <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br />coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br />owner, the party must acknowledge this responsibility for the billing by signature and date below <br />Name g Address AD 60/. , t&A-0(16lJ.4VI4hone # -g") <br />Signature. <br />EH230038 <br />(revised 1/31/02) <br />