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• <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3R° 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 />1 EPA SITE 9 ; PROJECT CON'T'ACT 6 TELEPHONE N <br />1}____________________________________________________________________________________________________________________________� <br />F 1 FACILITY NAMEK P14 NE 11 <br />C ADDRESS �� 3---L 'C^ j '-� `'�C'-jJ/� (/-i/Cz%%---C�---�J ��J----------------------------------- <br />I I }-------------- - ' <br />L ; CROSS STREET <br />I 'T OWNER/OPERATOR PHONE 11 <br />Y <br />_________________________________________________________y________________________________________; <br />C CONTRACTOR NAM° ��>�Gnol� - PHONE 11 <br />i0 +__________________ __-----------------------------------------------________________________________________ <br />N CONTRACTOR ADDRESS �� C-� _ /_� ,/ _ - -- _-----= CA LIC 11 -7 V', 1'60 = CLASS <br />T ------------------------ K JOA p4 _ _--------- <br />i 12 INSURER --------- <br />--% iz ---s— - — <br />C OTHER INFORMATION <br />0 1 I PHONE II <br />PHONE II <br />,III' __________________________________ <br />____________________________. <br />TANK ID'0 TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />T . •9g. <br />A 39 - <br />IN 39- <br />K 39- <br />39- <br />39- - <br />APPROVED; „ I I APPROVED' WITH1 CONDITIOq,(5' f " 11 SDI SAPPROVEDI <br />A 1E TACHI•IENT WITH CONDITIONSI <br />I N ; PLAN REVIEWERS NAME DATENo <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 CER'T'IFY <br />THAT IN THE PERFORMANCE OF THE 14ORK 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 PERI4IT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF <br />CALIFORNIA. -APPLICANT'S SIGNATURE: TITLE C71-�'Y Ct. //ICGYII.'/_// DATE <br />, <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 />0 <br />EH230038 <br />(revised 1/31/02) Vy�s�6 I� CBS <br />