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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3ND 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 /> ----------------------------------------------------------------------------------------------------------------------------------- <br /> mcr <br /> I I EPA SITE # ry tl_7-------- ------- N----- 6 ----- --- #__________________________________________________I <br /> t_______________________ SUSS__ I- ________________________ <br /> I F I FACILITY NAME <br /> A --------___________Trn�_£____o_ ______________________________ ---. ----J? _7 - ?i <br /> C I ADDRESS 1406-1 <br /> ) 1 <br /> I .___ ________________________________ ___________ ____________________1 <br /> L I CROSS STESET I <br /> I ________________'____________________________________________________________________ ____I <br /> T I OWNER/OPERATOR I FSONE # <br /> I Y I 7'(IiYI C at <br /> I _1 -F <br /> '-------------- <br /> C I NNIFACIUR NAME _ ��(� I PHONE # I <br /> 40 <br /> T I CR------- ADD-ESS-------------------------------- --------------� --LIC# V— -- 7 fJ i cross I <br /> T _______________USES_ __________ _______________________ ____________________I <br /> R I INSURER I WORK.CODIF.# I <br /> A -------------------------------------------------------------------------- <br /> O _____f____ <br /> C OTHER INFORFATION �,7 1 <br /> _____________ <br /> SUSS qq <br /> T _____________________________________________________________fi_I.._ ______ _______,______________ _/_____________________I <br /> 1 01 PWONE # I <br /> IR ___________________________________________________ _____________________,________________________________________I <br /> I I I PHONE # I <br /> ___IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII___________________________________________________ ____________________________1 <br /> I TANK ID # TANK SIZE I CHEMICALS STO CNRRENILY/FSEVIWSLY DAIS USP INSTALLED <br /> 39- I 1 <br /> IT139- I 1-1 <br /> A139- I I I <br /> IN139- 1 <br /> IR139- <br /> 1 39- <br /> 1 39- <br /> +---IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIt <br /> PI <br /> L APPROVBD _APPROVED WITH LTkIDTTIW(S) DISAPPROVED <br /> A (SEE ATTACHF9RiT WITH CONDITIONS) <br /> N PIAN REVIEWERS NAPS DATE I <br /> +---IIIIIIIIIIIIIIIIIIIIIIII1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 <br /> I APPLICANT MJ3T PERFORM ALL NORK IN ACLOROANC6 WITH SAN JOAQUIPI NUN1Y ORDINANCES, SIATS LAMS, ANO RULES AND RPGUWTIWS OF I <br /> SAN JOAQUIN NQNTY, ENVIRONMENTAL HRALTH DEPARTMENT. OESER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLIAWING: "I CERTIFY THAT IN THE <br /> PERFORMANCE OF TNE {CORK EOR WHICH THIS PSRMIT IS ISSUED, I SHALL NOT E WY ANY PERSON IN SUCH A NASSER AS TO I <br /> BENNE SUEJECI W WORKER'S NMEFNSATION LAWS OF CALIFORNIA." CON'TRACNR'S HIRING OR SUBNNTRAClING SlGNATNRE CERTIFIES TME I <br /> FOLLONING: 'I CERTIFY THAT IN THE PERFORMANCE OF TIS WORK FOR WHICH MIS PERMIT IS ISSUED, I SHALL SMEIAY PERSONS SUBJECT TO WORKER'S <br /> NMEENSATION LAMS OF CALIFORNIA." <br /> I I <br /> I I <br /> I � /� I <br /> APPLICANT'S SIGAIURE: L� TITLE T�_7cl f i I l_t01...DATE <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 owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name Address Phone# <br /> 1 <br />