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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE.3R0 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 /> : EPA SITE # -_-_ - <br /> 1 PROJECT CONTACT 6 TELEPHONE #-�� A�,-y J'-)i 3-- 4 q%_3�t,:- ' <br /> ----- --------------- --------- -- - <br /> F : FACILITY NAME F' n`a t'A O , PHONE # <br /> 1. C - -------------------------------------------------------------------------------- —`----- <br /> A------------------------------------- <br /> C : ADDRESS 111 9A , <br /> - ------------------------------------------------- ---------------fi <br /> L : CROSS STREET <br /> T : OWNER/OPERATOR P <br /> (�p HONE # <br /> Y B[ L E S. C o A S D. l L '1 1 g------------------------------------ <br /> C <br /> ? -----------------------.-C , CONTRACTOR NAME S J h;�A t) CQ C A C.t (�-C�_�-�-I-----------------------------------------PHONE # S u �CIU p O��- <br /> --- ------------ - -- <br /> CA LIC # <br /> : N : CONTRACTOR ADDRESS r S ,-{ C� S I )Q N A- (- <br /> nn CLASS <br /> C1 NU_ I L +_ ------------ ---------------�-----�-- ---- ----- <br /> R : INSURERAT <br /> - I WORK COMP-#,q <br /> S^ <br /> A7- ��r,? <br /> : C I OTHER INFORMATION ' <br /> --------i- <br /> T +------------------------------------------------------------------------------------------------------- <br /> PHONE # <br /> 0 ' <br /> ------------------ <br /> --------------------------------`- <br /> , ---- PHONE # <br /> ---------------------------------------------------------------------------------------- <br /> TANK ID #' TANK c_ZF : CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTAL:.ED : <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K , 39- <br /> 39-_- <br /> 39- <br /> i P <br /> 9- <br /> 39- <br /> P ' <br /> , <br /> L APPRO APPROVED WITH CONDITION(S) DISAPPROVED <br /> A 1 I '.SEE ATTACHMENT WITH CONDITIONS) <br /> W►# DATE <br /> N 1 PLAN REVIEWERS NAME <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULAT:CNS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: : CERTIFYTHAT IN THE <br /> PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS :SSUED, I SHALL NOT EMPLOY AE9SSQN IN SUCH A MANNER AS TO <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS C= CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERT:PIES THE <br /> FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE CF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT;TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE L C DAT^ <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 /> ralloml , lAe �14SY'y:,f Conc�/r�,i►sI ciS tfa�t� on �l ��e�1�i�j �rj[���cd�7crwv{ <br /> SR �s38d see �ltvlevf?� / �� gpi,,ved P.jt11�I�+��V Lt' C.na�r�fiwt� <br /> 0// sRoo3s388 0.� Stfe �� �H t/ems feursc). <br />