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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE. 3°" FLOOR <br />STOCKTON.CA 95202 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT. OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE DO NOT WRITE IN ANY SHADED AREAS INDICATE PERMIT TYPE BELOW. <br />---- TANK RETROFIT _PIPING REPAIRIRETROFIT ____UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />----------------------------------------------------------------------------------------------------------------------------------- <br />EPA SITE k ', PROJECT CONTACT & TELEPHONE # <br />--------------- ---- – –----------------------- --------------------------- – ---- –------------_------------------------ ---- <br />F FAC::.:T'! I7A'!_I. C"�,�` ; 2HONE # G <br />A _ <br />_-___-___.-_I.F�VCS____ ililyll'_ .-_�1-!-�_________________________________-----r-_lr__1��� <br />L ?'jSS --TREE- <br />------- - <br />-TREE---------- -------------- – ----- ------ ------- – ------------------------------------------------------------ <br />7 <br />---------------- <br />OWI:EF./OPERAT: F.!%� PHONE # S�S U% 0 <br />1 ed—/�e <br />______._._____.._.___t__._._.____5___�___c__�____�__e__�_.___5__�_-___________________________________________________ <br />_____________________________ <br />PHOITE�' <br />---------------- <br />1-017T?ACTOR <br />-TZ:iS�r.EF. ALDRES <br />------------------------------------------------------------- <br />CALIC# <br />____----- <br />------ <br />- <br />_-------- _G <br />WORKCOMP.# 1 <br />. SA� -------------- ________________________ .--------17377G -- <br />-____________________________________________________________________________________r___________________--__---__---------_-_II <br />PHONE # <br />R----------------------------------------------------- – ---------- – ------------- – ------------- <br />PHONE b <br />------------------------------, <br />TAW.:., - TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />39- <br />N 39- i <br />is 39- <br />39- <br />39- <br />L <br />9 -39- <br />39-L APPROVED APPROVED WITH CONDITION(Sr* DISAPPROVED <br />A SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME _ DATE <br />i <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY, EN\-IRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 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 <br />CODJPENSATION LAWS OF CALIFORNIA." COh'TRA(^'OR'S HIRING OR SUBCONTRACTING SZu-PLATT=.E RT:r':ES THE <br />FOLL,9KING: "I CERT: --Y THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />CCD:?KNSA7I:1?: LANs <br />A PLICAM.'S SIGNATURE: ��j,.�OL�iln Vim-+ TITLE DATE >, V ! <br />---------------------------------------------------- ----- <br />1, �kai0ls. 1, f fv�l� f.•A� �0 <br />BILLING INFORMATION: r UV�LV &Dfes–. <br />12, (� ; vac., � � � < . I� <br />3, C R vt n'c- I? q (V s- Cl I Lt I <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 owner, <br />the party must acknowledge this responsibility for the billing by signature and date below. <br />Se�v�s Sk�tvr\�S�^� <br />NameAddress b80_—Phone#��3�-?!! <br />1 <br />