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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3"O 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 REPAIR/RETROFIT_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> ; EPA SITE # ; PROJECT CONTACT 6 TELEPHONE # <br /> ------------------------------------------------ --- <br /> F FACILITY NAME I PHONE # , <br /> A +___________________________________ ________________________________________________________________� <br /> C ADDRESS <br /> L ; CROSS STREET <br /> T OWNER/OPERATOR PHONE # <br /> Y <br /> r <br /> -------------------------------------------------------------------------------------------------------------------------------- <br /> C I CONTRACTOR NAME I PHONE # <br /> N ; CONTRACTOR ADDRESS ; CA LIC # I CLASS <br /> R INSURER WORK.COMP.# <br /> C OTHER INFORMATION <br /> 0 ; I PHONE # <br /> R <br /> r r <br /> PHONE # <br /> rrrrrrrr�i r <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> X 39- <br /> 39- <br /> 39- <br /> }___ rrrrrrrrrrrrrrrri rrirrrrrrrirrri rr ri rrrrrrrrrrirrrrrrrrrrrrrrrrrrrrrrrrrirrriiriiirrrrrrrrrrrrrrrrrrrrrr,r„rr i <br /> P <br /> L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> ; A (SEE ATTACHMENT WITH CONDITIONS) <br /> ; N PLAN REVIEWERS NAME DATE <br /> }___ „rrrrr.........r. r...rrrrrrrr.. rr,rrrrrrrrrrrrrrrrrrri r. rrrrrrrrrrrrrrrrrrrrrrriiiii rrrrrrrrrrrrrrrrrrrrrrrrrrrr <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." <br /> APPLICANT'S SIGNATURE: TITLE DATE <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 Address Phone # <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />