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Sep 02 04 07: 34a Mik- Rotten <br /> UP/'AIZIDe4 kb:E.s 1l9�4h1 Ij [20911 533-2650 � <br /> - h 11- 1 H 1-LuuU e h'AL�t p!p <br /> \4. <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE.3'FLOOR <br /> STOCKTDN,CA 952D2 <br /> APPUCAT!0N FOR UNDERGROUND TANY RURO;IT,OR PIPING REPAIR PERMIT <br /> THIS.PERMIT EXPIRES 90 CAYS FROM THE APPROVAL DATE, 00 NOT WRITE IN ANY SHADED AREAS.iNDICATIE PERMIT TYPE BELOW: <br /> TANK RETR©Frr PIPING REPAIRiRETROFIT - - TA:N _NT#iEPA1RiR'C FfT <br /> ---------------..---- ---- <br /> I I EPA SITE R ____ -___ <br /> r __.._..�-PAO;.ECT C.OWTAC7 F. TE:4PH[]NE g __ ___________________� <br /> I F , FRCILIIY 6f Ns£ W� ! -'L-0 <br /> A •- - ._. -•-- ` Z! @HOSGlj`f <br /> I C I ADDRESS Z S7J C - --- "_R, _ -- -•-- - -- -- - - -- -- <br /> II - - - -- -- - - <br /> I L CRQ56 STREET -- - <br /> II ----------- -------------------------------------------------------- --------------------------------------------------------- <br /> T '� CHNER/OPERATOR -I PROM£ A <br /> IYI i <br /> I C I CO:rrBACTOR Nwr /7 L e rg___....._____.___ ------------------------------ P ' ZU �5 �_. __ ,....i <br /> �61 <br /> 04.... --•------- ----------y------}-------'-------------•------------------ -7340 <br /> I COWTkACTOA AD9H6S5 '7 .4J" �J!/ '�' ��t'j:' CA LIC ii � Z� I CLASS <br /> R I IH63fREC <br /> I , f - ..........................I rn� O� i —A' aa - fs� -j _! <br /> --_-_____ - _ - _ ----------------------- ----- __---_-.___ -------------------- <br /> C <br /> _ _ _-_-. <br /> -/.. _ <br /> C OTHER INFOfewfl Y <br /> 9A ---------••-•--•------------------------• ----- ----•--------- <br /> - "-- ------ <br /> YfiON£ i' <br /> i <br /> j R '....--_-.- ----...._........... .......... ---------- ---------------•------i @-----i <br /> ----------------------------- 1 <br /> ♦-.,IIIItIIIiIIIfII111111111I1I11111 - - ---------------•---.....I <br /> TRNSL I!i b TANK SIZE I CHEMICALS STORED 4lIRREh—Y/PREVIOUSLY I £ATE UST INST-ALLED I <br /> 1 <br /> 39- <br /> 19- <br /> 39- <br /> L <br /> 9-39-39-L I APPROv'CD APPRCV90 WIle CONDITION m DISAYPROV90 <br /> A I ISEF. ATTA'CNMFNT WITH [ONDITID:75! <br /> pl j PLAN REVIEWERS "AMP. IVATS <br /> +-'-iilllilE1111111111111iV l;llll9.� ,1111111 111611111 ,1.11111 III1 I� ,,,,,11161 I IIIIIIIi�I�Iillllllli, 116;IIII..,i�' <br /> I <br /> f APPLICANT !tD$T PERFORM ALL WORK 1Is RCMADAIJCE m,ITSt S)uV .TCJR@UIN COIRlTY ORDINANCES, STaT$ LR'-C9, AND AVI.i9 AND Rr'LIT..ATIC"IE OF <br /> { SA.0 ,347AQUIN COUNTY. MVIRUUMENTAL 11FAi.TH DSPART4A1T. OWNER OR LTCWSED AGENT'S 3ICN;tTURE CETt'33'I£S THE FOLLOWING: -I CERTIFY I <br /> THAT W THE PMFOW}ANCE OF TRI-' WORK FOR 4NICH THIS PERMIT IS ISSUED. L SHALL NOT F;MYLOY hlPY FL'R^+ON Thi 3lSC3I A MANNER AS I'O I <br /> u LDCOMS 9JEJLC? TO WORKER'S COMPEMSATION LA%S OF CRLIFORITIA." CONTSLACI"OR'0 VXRINC OR SUHCON711ACTTNG SIC;NATURE CERTLFIES SHE 1 <br /> POLLDMIHG: -I CERIIFY THAI IN 173EPV1r0AMAHCE OF WORK FQR WSIICSI THI° PERMIT IS I66UED, I SHALL LIFLUT PEP.SONS SVJJECT TO <br /> WORKER'S COMPENSATION LAW,^, OF GILI FORY[A <br /> _e.- _ <br /> 71APLi®SNS'9 $IG17A'PJ'RE: - ?ITLE =�""`r DATE; --< <br /> I _ ___ ________ _________________......_-_---_-.-__•___-.-... <br /> �..... ............................ <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. propert} <br /> owner, the party must acknowledge this responsibility for the billing <br /> —by signature and date below. <br /> Name r Address J 7 7 <br /> Signature _ f <br /> EH230038 <br /> (revised 1131102) <br /> 1 . <br />