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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3flC 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 REPAIRIRETROFIT <br /> _____________________________________________________________________+ <br /> EPA SITE # PROSECT CONTACT 4 TELEPHONE # fl✓ KA/L'___ ✓x1'C J____-F1�1 -I- //IJ <br /> PHONE # <br /> F FACILITYNAME 4l_>I_!A' -----_l_l-lam Ls __slLII-•------------ -------- <br /> C ADUR&SS �l.�l___ _--- C'1ih_S-�---------------------------------------------------------------------I <br /> I +_______________ <br /> L CROSS STREET <br /> T j OWNER/OPERATOR <br /> PHONE # <br /> Y <br /> -------------- -------------------------------------+---- <br /> C I CONTRACTOR NAME _y IraIrs----'-----I PHONE #�- <br /> N CONTRACTOR ADDRESS � ,__,(� a_-----------------------CA LIC #/�/G.•Q_______ CLASS___�`�_I_____-_____i <br /> __ _%Aft _ISl7/1J__J <br /> R INSURER S� 1 WORK.0 '.# 173 x'1_03-_____ <br /> w� _ _??_``��__ J_ <br /> _________ _____ _ <br /> C 1 OTHER INFORMATION I <br /> ____________________________ __________________________-________-___I <br /> T +__________________________________________ FROM # <br /> 0 <br /> -HONG # <br /> IIIIIIIIIII11111111______________ <br /> ______________________________ <br /> _________I- _______________ <br /> TANK ID <br /> TANK SIZE CHEMICALS SIQRED CURRENTLY/PREVIOUSLY DATE UST INSTALL.® <br /> I � # I I I <br /> 1 39- <br /> T ' 39- <br /> A I 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> ---- <br /> 9- <br /> 3939+___ ill l l ilii iiiii l llllll llllllllllll lilllllllllllI M 1111111 lHi ll�I l illlill-If 11 11II11M Illilli 111IIIIIH M 11HIIIIii <br /> P Iii J(� <br /> 1 L '��� 'III'1I APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> AI (SEE ATTACIAID�TT WITH CONDITIOM) O l la� <br /> N I PLAN REVIEWERS NAME 2 - DATE o/ r <br /> ___Illllllllllllllllllll IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIillllllllllllllllllllllllllllllllllllllllllllllllllllllll <br /> I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE NIM SAN JOAQUIN COUNTY ORDINANCES, STATE IANS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOI,. ING: "I CERTIFY THAT IN THE <br /> PERFORMANCE OF THE NOR, FOR NHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO I <br /> l SECOME SUBGECT TO WO,,,,.S COMPENSATION LAWS OF CALIFOISIIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSURD, I SHALL EKPLOY PERSONS SUBJECT TO WONPEF`S <br /> N PENSATION LANS OF CALIFORNIA." <br /> APPLICANL'S SIGNATURE: /J TITLE DATE <br /> ��s/off <br /> r <br /> __ <br /> ____ _ _ ______ <br /> ------------------------------------- A-0 2q jfV%&1 <br /> ------- Twp F b6 I r6F+3 EN_ ___cw.w� <br /> BILLING INFORMATION: 2 Sc�Gadvw qn Appokli, oV (41�r•N6411a) h� e� <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 /> �vwIL�S �c c� Qo'M . <br /> Name___�S�SAddress____<;, _—------Phone 113 <br /> 1 <br />