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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3RD 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/RETRORT--UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> _-______ <br /> 1 +--------------------------------------------- ---------------- __ ___ <br /> ------------------ KRET------z--------- <br /> EPA SITE # <br /> PROTECT CONTACT & TELEPHONE # ' /�/ -- '© <br /> F' FACILITY NAME �y'3� �'� ______a_____ / __ <br /> f✓J CT (J/ --+ <br /> Al-li <br /> C - ADDRESS 3� �� ,(-f---�-j-�-,r�--�- --PHONE_#(� ------------------- <br /> I <br /> l7 <br /> L I CROSS STREET ----'--- -- _5�._____________/e if/-�s/(� -' <br /> ------ -----^`_-----'-------"------�---'------ PHONE #----------------------------------------- <br /> Y <br /> ----- -----`----- -i <br /> P T OWNER/OPERATOR n <br /> Y �POfeT 1' ---H--------------- <br /> N CONTRACTOR NAME _ � "` �Y __ <br /> +---------------- oti , -- -------r � 7�s <br /> CONTRACTOR ADDRESS -------- �/�� _ PHONE # - ---- -' <br /> T +-------------- --5_rte _-'------_-----------------'------- '� 37 <br /> R INSURER '---�---� _�___�11�=_F L £�� CA LIC # --�-- -- - <br /> A '---------- `____ CLASS -A <br /> _ Tt`fT 2Wi?�i✓s� ---------`f3?Od---------- <br /> --- ------- F` h� <br /> C OTHER INFORMATION _____________ � ____________________+-WORK_COMP_#_ �/D� �Q <br /> , O <br /> -------------+----- ' <br /> ------�-'--�----- PHONE __`___----' <br /> - <br /> ' HONE # "- ' <br /> TANK ID # � '--"--- _ '_------------------------------ <br /> T <br /> __ - <br /> k____�_____________ _ __ _ <br /> 3g TAN[( SIZE CHEMI LS STORED CURRENTLY/PREVIOUSLY <br /> T 39- -DATE UST INSTALLED <br /> A 39 - <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> 9-39- <br /> 39- <br /> L "I'IRPPI,,,i,,, 1 'AFPROVED'WITH1CONDITION(S' <br /> A I DISAPPROVED <br /> N PLAN REVIEWERS HAKE CHMENT WITH CONDITIONS) <br /> '.III III..:;11 l ;Ifl 11 l; ,I;I DATE 2 D <br /> APPLICANT MUST PERFORM", EN ALL WORK IN ACCORDANCE <br /> SAN SOAQUIN CO[RPfY, ENWITH SAN 17OAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OVIRONMENTAL HEALTH DEPARTMENT OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTFIFY <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 <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CA.LIFORNIA.° CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE TO <br /> CERTIFIES FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PETHE <br /> CT TO <br /> WORKER'S COMPENSATION LAWS OF 'IIA RMIT IS ISSUED, I SHALL EMPLOY PERSONS CERTIFIES <br /> APPLICANT'S SICLRATURE: <br /> TITLE <br /> .__ - ' <br /> Q��_ DATE �'^3 <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. property <br /> owner, the party,must acknowledge this responsibility for the billing by signature and date below. <br /> Name ,c%cam,Pi„r ,�' AddressesIMI&AWAlk Phone <br /> Signature <br /> E H230038 <br /> (revised 1131/02) <br /> 1 <br />