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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3A0 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__-I EPA-SITE <br /> _#_____ _______ ___ _____ I PROJECT CONTACT & TELEPHONE # 5:: J_ I ___�(�� _____� � J.____I <br /> __/_�_ ____ ___________� Y�'FS <br /> I P i FACILITY NAME / // / �j i PHONE # <br /> A _________________ __ ,_,, ,f/e`�,eT_,_/_J__txG_______________________ ��1JQ,�3_f,�g-_____j <br /> I « ADDRESS------1?_8-y__ C /�J [___C�IIT --------------------------------- <br /> C {/y- ---------------------------- <br /> I ` CROSS STREET LSA/A_--^"'2�PIsLLs'L] ------------------------------------------- ------' <br /> ------------------------ <br /> Y OWNER/OPERATOR �� I I I � //I/. i PHONE # <br /> /---- CT LzoY '?33-/74?-_7 i <br /> 1 <br /> c I CONTRACTOR NAME I.ilC./__e{ __> N_1�l.Pe7 -- _ �Je-rC�J_ -5,-----_PxoNE N ----- - $33-02---{�---I <br /> 0 ------------------- <br /> N I CONTRACTOR ADDRESS V C D s CA LIC # 6�!SD I CLASS I <br /> � -------------------- 1---- <br /> I T • --SUREI <br /> R I INSURER J_ �KK�_-_ I W----COMP-- DQ �--a O �L <br /> I C NF <br /> I <br /> OTHER NFORMATION__________________________________________________________________I <br /> T*'- HER _______________________-________________I <br /> I <br /> I o 1 1 PHONE # I <br /> 1 R _____________________________________________________________________________________,_________________________________-______I <br /> 1 1 I PHONE q <br /> IIIIIIIIIIIIIIII1111111111111111--------------------------------------------------s----------_-------------------------------- <br /> I <br /> I I TANF) I TANK SIZE CHEM CALS £'fjW CURRENTLY(PREVIOUSLY 1 DATE VST INSTALLED <br /> I I 39-T 39- <br /> fl 2 CJID uNL /f0.✓ �a,+•_ 1 Tar <br /> T A 39- <br /> N 39- 1 <br /> K 139- <br /> 39- <br /> ---lillillillilllililllliiiliiiiiiiilllilllllllllli ' IIIIIIIII I Illllliillliiiliiillllllllllllllllllllllllli <br /> Hill I Hi: liiiiiiiiiIli <br /> I L APP VID APPROVED WITH CONDITIONS) DISAPPROVED l <br /> A I SEE ATTACHMENT WITH CONDITIONS) <br /> I N I PLAN REVIEWERS NAME DATE I <br /> -"Illllllliliiillllllililill � liilllliiiiilllil Illlllilliiiliiliiilllllllllllll II Illilllllllllil ii II illillliiiiii <br /> I 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 THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUM 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 I <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA.- // /) <br /> �'" <br /> I APPLICANT'S SIINA TITLE /MIec GTL• DATE <br /> I 1 <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 /> Gc'r� of f_. 1we41A / / / <br /> Name cc Address to 2 E. �D� S- rre- Phone # $33 07Z <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />