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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3R°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 —4PIPING REPAIRIRETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +-------------------------------------- ------------------------------------------------------------------------------------------t <br /> I EPA SITE # ; PROJECT CONTACT s TELEPHONE # <br /> +--------------------------------------------'-'---------------------------------------------------------,,,-/------------------------� <br /> I F /pf <br /> FACILITY NAME A7N !; 4W 3tL- <br /> j- -------------------------------------------PHONE N (�4 --�� l r- — -", <br /> , <br /> ` / <br /> I ADDRESS 5 <br /> 4 GA l >--Si---- <br /> L 1 CROSS STREET ' <br /> ' I +-------------------'-----------------------------------------------------------------_----------------------------------------I <br /> , <br /> T ; OWNER/OPERATOR ; PHONE # <br /> Y IN ZQ �3? ' <br /> '--- ".------------------------"-------------------`--------------------------------------.PHONE ( <br /> C <br /> --- <br /> C + CONTRACTOR NAME (N,II,.�(N)t' �°+t rt.'rs�'�------``�`-1-L----------------------'HONE #-(910-&`16-9(-so ------ <br /> 0 ----------------------------- <br /> N ; CONTRACTOR ADDRESS 3V imAj\,1 h�s�,r 5vly 55A (A �I CA LIC # 0o)yS : CLASS A6 C/-(' d llo t <br /> ' T ---------------------- - a ---------- ------------- ' -------------- v--I------------; <br /> R I INSURER ; WORK.COMP.# , <br /> ' A '------------------------------------------------------------------------------------------------------------------...----------s <br /> C OTHER INFORMATION i ' <br /> ' T +-----------------------------------------------------------------------------------{----------------------------------------1 <br /> 0 I ; PHONE # I <br /> ' R +--------------------`---------------------------------------------------------------------------------------------------------I <br /> PHONE # <br /> +---1 1 111i11;.I.11 1111191111111'--------------------------- -------------------------------------------------------------, <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED ; <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> 1 <br /> , K , 39- ' <br /> 39- <br /> 39- <br /> +---1,111,,,,,,.,,111„ <br /> P 1 }// Ir\ <br /> L 1 APPROVED _APPROVED WITH CONDITION(S) DISAPPROVED <br /> A 1 � �(/�J�f� (SE %NT� _WI ONDITIONS) <br /> N PLAN REVIEWERS NAME_ I#��rl1L6 60 -e � -- <br /> DATi <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 1 THAT IN THE <br /> PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO , <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE , <br /> ' FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATILAWS OF CALIFORNIA <br /> ' � t� <br /> APPLICANT'S SIGNATURE: I TITLE DATE/r Q� <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 owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name 6f-7?-rJ N tool ki Address SO O N s S �A Phone # (91421y& 7(c�Q <br /> 1 <br />