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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,eo 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 /> —)9ANK RETROFIT_PIPING REPAIRIRETROFIT_UNDER DISPENSER CONTAINMENT REPAIR(RETROFIT <br /> _______________ ____________________________________________________________________________ <br /> I £PA SITE Y --_ -_- 1 PRDJSCT CONTACT 6 TELEPHONE Y <br /> _____ I PHONE N I <br /> __ _____ __ ______ <br /> { P I FACILITY NAME ,y� <br /> IA ------------------- - - - C�"�q �_�t-"_r= ---------------------------------------------------------------� <br /> I C I ADDRESS I( __W-'--'c ` I <br /> I _____________ <br /> ________________________ <br /> { L { CROSS STREET - <br /> { I +____________________________1v --------------------------_______ ________________________________________________________I <br /> T T I OWNER/OPERATOR PHONEY <br /> I Y I LAWS Jr� P(5�5 I <br /> I + /� ff y4 <br /> { C I CONTRACTOR NADffi /� p /_E�2J�y_ ,ryL I PHONEY q//___ZD________ ��____I <br /> { H I CONTRACTOR ADDRESS I CA Lxc Y (p 3 8 I CLASS — 1 <br /> { A { INSURER ____ ___ _ _ WORA. <br /> COMP <br /> ____ <br /> I C I OTHER INFORMATION <br /> T +________________ 1 PHONE III <br /> - I <br /> ID { _________+________________________________________{ <br /> _________________________ <br /> { R +___________________ { PHONE R { <br /> __________ <br /> ___________ii___________________ <br /> CECURRENTLY/PREVIOUSLY DATE V��ALLED <br /> TANK ID Y n0 �SCme-J39 <br /> T <br /> 1 39- <br /> A 39- <br /> N 39- <br /> 1 1 <br /> I K 139- <br /> 39- <br /> 39- <br /> + <br /> 9- I I t <br /> I 39- { { { <br /> { { 39- I <br /> iillll II 1111 ) III 1 lllliiiill I{�I X11{II{ Ilili 1{II {11 {{ { II 1 I 11i I 11111{ 11{I{i <br /> P Yx— <br /> L APPROVED APPROVED HITH CONDITION(S) DISAPPROVED I <br /> A . )SEE ATTACHMENS WITH CONDITIONS) <br /> 1 IO �V <br /> 1 N { PLAN REVIEWERS NAME DATE <br /> +---IIIIIIIIIIIIIIIIIIIIIIII I IIIIIIII III 111111 11111111 II. II III I � 1 � IIIII11Ti )III. 111111 f��� <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF I <br /> I SAN JOAQUIN COVNTY, ENVIRONMENTAL HEALTH DEPARTMENT- OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY I <br /> I THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO I <br /> { BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I <br /> { FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO { <br /> { WORKER'S COMPENSATION LAWS OF CALIFORNIA.- <br /> { I <br /> I /�Q�� p I <br /> I `vim"�II���b DATE �� I <br /> 1 APPLICANT'S SIGNATURE: TITLE <br /> I <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 Ae.11,420 AAddress /769 61, 04/ --zr2 44 Phone# <br /> Signature_�� <br /> EH230038 <br /> (revised 1/31/02) <br />