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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3P0 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 />_____________________________________________________________________________I__-_____________________ ______+ <br />+ ! EPA SITE #- - -------------------------------PROJECT CONTACT fi TELEPHONE N Nn . Lar �W-4-ft--t _ W" <br />---- - USA (h" s�tn� ) 41 5 w]Lo WY Woo(�{LS19 <br />F ; FACILITY NAME _.____________________________PHONE NQ-J_�l t9� •��____- <br />Aa____________________ _J_ <br />C ! ADDRESS .21aA <br />I--------------------- <br />L ; CROSS STREET <br />I--------------------- <br />T ; OWNER/OPERATOR Ji <br />Y <br />i_ +____________________ <br />. ; C ;'CONTRACTOR NAME S. <br />0 --------------------- <br />N :CONTRACTOR ADDRESS <br />TF___________________. <br />R ; INSURER <br />A <br />C <br />O <br />R <br />T <br />A <br />H <br />K <br />-----433---SOg-----_, <br />_PHONE# J4AV--'11R./AAte' R <br />; CA LIC It If %9 / '914 ; CLASS <br />____________________________________ <br />I WORK. COMP. # jn i G <br />C(.1 <br />OTHER INFORMATION <br />+____________________________________________________________________________________+_____-------____-----_____-_------____--� <br />; PHONE # <br />+------------------------------------------------------------------------------------+---_____----_______---_______-------____i 1 � <br />PHONE # <br />_____-___-TANK_--______-_____-_EHECHEMI___--________-_ <br />________________________________________ <br />,"""•III <br />�rwvr m a TANK SIZE ; CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED , <br />P <br />L : APPR D APPROVED WITH CONDITION(S) DISAPPROVED <br />ADATB <br />.; TTACHMENT WITH CONDITIONS) <br />! N ; PLAN REVIEWERS NAME / <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 <br />THAT IN ME PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO ; <br />' 9ECOME"SUSJECI 2O WORKER'S- COMPENSATION LAWS OF CALIFORNIA:"- CONI'RACTOR!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. I.. . <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA.- <br />APPLICANT'S SIGNATURE: fyl(�1-I.�A�+I�/"•�' rte- — TITLEJ�w'�+�lY�^v <br />y________________________________________________________________________________________________________________ ; <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 Kar-t&tV- L dHPddress kV D Q Viu4 iU-e. Phone # <br />Sig <br />EH230038 <br />(revised 1/31/02) <br />