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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304E 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 REPAIR/RETROFIT <br /> ------RE------ _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> ---------------__________________________________________PAIR__ <br /> I I EPA SITE k ____________ <br /> _______________________________________________________+ <br /> ___________________ pR �CONfACf & TeLEPHON6 # <br /> I F I FACILITY FAFBi I <br /> A + -- 1IV t�RA ---------------------------------------- <br /> CPHONE <br /> k?- <br /> I ADDRESS _ --- ----- # O+ aY ----`---G'-- r �� i3iyT iy <br /> I L I CROSS STREET . _ _ <br /> I I +---------------------QRST/ .7'�Pil---y--� ---9.5' 7_x------i <br /> / <br /> I T I OWNER/OPERATOR ___E_____________________________________ _ <br /> YI _ _____________________________________________________I <br /> G [ ioRn�iA PEONS�A 5 57,a # <br /> ID CONTRACT-R ---- - --------------7/O/V_-GLG_____--_-+_a <br /> -- --- T I FROM # �} <br /> I N I ------CTOR ------ADDRESS 70_______ FROM #.?,,I <br /> ___ _ .�OL� �sd3)�C7.S PAPP <br /> -- <br /> I R I INSURER �JJ�:6/ I G LIC # �S/Sp ______________________i <br /> Cuss <br /> IA __________________________________________________,____ ______I <br /> I C I OIIf6R INPOFIMTION I WORK.Cv^l�,p <br /> IT +_______-_____ _ ___________________________________I <br /> ____________________________________________________________________I__ <br /> lol I <br /> IR +________________________________________________________- ______________________________________I <br /> i I I PRDM # _________________ __ I <br /> + -IIIIIIIIIIIIIIIIIIilllllllllllll __ _ _ __ _ <br /> I I TAN[( ID# _ I -----FRORe k <br /> TANK SIZE ___________________ <br /> I 39 —I 1 CNEMIGIS 51P1 CURRENTLY _I <br /> I T 139- I /PREVIOUSLY I DATE UST INSTALL® f <br /> I A 139-��1 <br /> I N 139 <br /> K 39—�I <br /> I 39- <br /> I P <br /> 9-IPI <br /> I L APPROVED <br /> IAAFFROVEO WITH CONDITION(S) pISAPPROVED <br /> I <br /> I N I PLAN RRVIENSRS NRME 1 1.n'(_ 158E ATTAtRR.>&t�+T WITH CONDITIONS) <br /> MIR -05 <br /> llll�ll10115llllllllllll <br /> I I <br /> I APPLICANT MOST PERFORM ALL WONR ltd A,,RDANCE N=TN SAN JO WIN COUNTY ORDINANCES, STATE LAWS. AND RULES AND <br /> I SIN JOApUIN COUNTY' RNVIRONNENIAL HEALTH DEPARTWNITI'. MIRR OR LICENSED AGENT'S SIOIDITURE CERTIFIES THE R6Y..INITIONS OF I <br /> PERFORMANCE OF INE WORK FOR WRICH THIS PERMIT IS ISSORO, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER ASFO"I'ON NG: "I CERTIFY <br /> I BECOME SUBJRCl Ill WORRett'S COMP I I I THAT IN THE <br /> I FOL=IATION: "I CERTIFY THAT IN THE PTERFORNANCE OF INE WOREIAFOR-'I IRIS PERMIT ISOIESMMNI SNnr* SI@AIVRE CERTIFIES TNS I <br /> 11p6NSAIION LAWS OF CALIFORNIA," EF@LOY PERSONS SUBJECT TO I I WJRREE'S <br /> I I <br /> I // I <br /> I APPLICANT'S SIR TUR5: / iWa47 Vn• /111;1 A46 TIM,el,e.9kPTA/e�i M. <br /> --------------------- -- <br /> -k (�2 C-\19- vQGR/o-oE --------------- <br /> --------- I <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 s �I-, Address a� <br /> ��17��" � �1k..� � Phone <br /> i <br />