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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3RD 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 /> JVq+Lk, X TANK RETROFIT_PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +--------------------- --------------------------------------------------------------------- - - + <br /> ------------ - <br /> ' I EPA SITE # i PROJECT CONTACT & TELEPHONE # O„l/���+�(- �,� �(, . 038 <br /> ' -� ----------------- - --------- -I <br /> F I FACILITY NAME Lov.e'b cQV t �{-py'�, ; PHONE # I <br /> A -----------------ass------ - ---------------------------------------------------------------------------------------' <br /> ' C I ADDRESS <br /> Q-01--- <br /> ------------------------------------------------------------------ <br /> L ; CROSS STREET Jo�L We- & ' <br /> II +---------------------- ------------------ �A�j -- -------- <br /> T OWNER/OPERATOR 1 PHO .. <br /> Y , LaveS Covv� y Stove. ( - <br /> ---+------------------- ---------------:---------------------- ---------------------+------------- -------------------------- <br /> C CONTRACTOR NAME PHONE # <br /> servcz- Sk tom_sc-------�s�,�c----=---==--=---. --- --`--��-13 <br /> N I CONTRACTOR ADDRESS 0 @ u l K� ve , CA LIC 0 8 S,$L�- CLASS a, CI41 a <br /> iT ------------------------- <br /> R <br /> - � - "� `--`----- ---------------------`--- ---------------- - - - <br /> - -- --- <br /> wakuatkc�Q `lt:E ouu:� i 3 $ <br /> I R INSURER �,il �� , WORK.COMP.# g .�' ' <br /> ----------------------------------------------------------------------------------------- <br /> C OTHER INFORMATION <br /> O I ; PHONE # <br /> , <br /> PHONE # <br /> ---------------------------------------------------------------------------------------------- <br /> TANK�ID #' TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED <br /> 39- <br /> T 1 39- <br /> A ; 39- <br /> N I 39- <br /> K 1 39- <br /> 39- <br /> 39- <br /> P <br /> 9-39-39-P i <br /> L ; APPROVED <br /> �� ✓APPROVED WITH CONDITIONS) DISAPPROVED <br /> A I ��PrRJG ( ATLENT WITH CONDITIONS) <br /> N ;PLAN REVIEWERS NAME -O DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> .•FOLLOWING: "I CERTIFY-THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,.-I SHALL EMPLOY PERSONS SUBJECT TO ; <br /> ' WORKER'S COMPENSATION'LAWS OF CALIFORNIA," /I�-. - - - -/ <br /> APPLICANT'S SIGNATURE: (/r�f�W�^'' / V TITLE � 6� �i. v 1"'`NATE <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 /> C- QrS-Ita- <br /> NametAA[?—Rt-� V' w6"µH1JAddress &VV 66A(/)NUec ScU Ok Phone# V.al-:34w <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> • 1 <br />