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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3RO 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 REPAIRIRETROFFT - --- -+ <br /> ---------------------------------------------------- <br /> ' ", EPA SITE # PROJECT CONTACT & TELEPHONE # <br /> +--------------------------------------�-- <br /> --- -- -- --- ------------------------------------------�Ho�HiQ___�� 3� _ __�zu=r <br /> 1 ; <br /> F FACILITY NAME �a S' _-----_1S~ ------------------------------------------------- 95- <br /> C <br /> ----------- ----------- ------ <br /> �,Q //�� Q rte•�'y - <br /> C ADORES- -- ----sm �-'--v \N'W------`.----------- �t-_-1-1 �'= -- ------ -7-------------------- , <br /> L 1 CROSS STREET <br /> ------------------------------- <br /> ------------------ <br /> ' Y OWNER/OPERATbC_0 5 T„_C_� PHONE # <br /> ---+-------------------------- -----+---------------------------------------- <br /> i c CONTRACTOR NAME ^o -. -�- - PHONE # x — -- p----- <br /> ---------------- ---------- <br /> ----------------------- <br /> L--LZ � ------------------------------------------ <br /> N 9 CONTRACTOR ADDRESS__j- 5�--- -�V .'�.��C'� ---- -CA LTC #---�Z�SZ.� ----CLASS <br /> ___�.I' `_F .--, <br /> T +-----------tt---/�--ww--�--�-] I /!� J� WORK.COMP.II <br /> R : INSURER <br /> A '------ ---- ---- 171 --- -- -_ ---------------------+-WORK-----.------- - - -----------I <br /> C 1 OTHER INFORMATION --__----' ' <br /> ---------------------------------------------------- +----------------------------------------1 <br /> 0 PHONE # <br /> ----------------' <br /> 1 PHONE # <br /> „ ------------------------------------------------------ W <br /> VK IDI# TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY LD <br /> DATE UST INSTAL <br /> 39- G' t 0dGc 02- <br /> 1 <br /> 21 T 1 39- <br /> 1 A 1 39- ►1 ....� <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> 9-39- <br /> 39-P 1 <br /> L APPROVED APPROVED WITH CONDITTON(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N 1 PLAN REVIEWERS NAME DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JQAQUIN 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 I <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> I 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 OFF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: , --^`- TITLE -- DATE <br /> , <br /> -------------------------------------------------------------------------------------+ <br /> BILLING INFORMATION- <br /> indicate the responsible party to be bille(i for additional EHD staff time expended beyond permit <br /> payment coverage per tank. If the party designated below is different than the permit applicant, e.g. <br /> property owner, the party must acknowledge this responsibility for the billing by signature and date <br /> below. <br /> Name t V-6 0 0 7T704 Address UTT-_72-CUP Phone <br /> Signature <br />