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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3� 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 />IVATANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />1 I SRA SIM _#_ '------------7 V-2 6, 1 PAOJECT NNTACT & TELEPHONE # <br />e - '�/aao37y�6-- �uvAEc c�« I-c� s9�•39�� <br />P i FACILITY NAME L I FHONE # <br />�uo`J----- Aiu/A! ----- G.C/c.[97iv.J -------------------------------------------------- <br />I C I ADDRESS Ar'%s E %c voeo /�./e. e 79ey �s<iFaw.,9 <br />11 -------------------------------------------------------------- ----�----------------------------------------------I <br />IL ----- ------ <br />I T I DIesR/OPewITOR FNaSs # <br />Y 1 flee - C� 2_,„��,���,.� Cs3o) ase <br />I---------------------- --- - -----------------------------------/-------- ------------------------------------------ <br />C <br />- 1 <br />Ic comNACTDR SANE �.CF"F_�-+�f� G V ✓iear /llil/f4_�---`_i�c�1 PNoae» <br />-- -----HO-E---------------------------------- <br />T{ (XaiTRACIOR ADDRES3 29Ga-Giunn�.l__sS'xe-_CB, [_a------ GI LIC» 16103------ --- 61 <br />R INSURER m9 V I wom.comF.» <br />A 1 asN_ GocAJ_�4Q,rN��. �A 19 io3-----------------HNC_ GS8o41- b <br />C OTFESt INFORMATION 1 <br />T --------- ls1 GA----- a/aaoy_7i-iz---- <br />1 0 1' » 1 <br />I R --- -/fo L------�--------- -----------S.90 5-9.? - /.2 <br />Igjy �FX) C iS) 1Y%• /367 1 PHONE» I <br />--1 1 1 1 1 1 1 1 1 1 1 1 1 11 1 11 1 1 1 1 1 1 1 1 1 1 1 1------------------------------------------------------------------------------------ I <br />TANK ID # TANK SIZE CHEMIWS SIORED CURRENTLY/PREVIOUSLY DATE UST I STALL® I <br />39- Al/ oirn 1 I <br />I T 39- —2 iif t7w 6 <br />I A 39- A, emlqF-2E 1 <br />1 N 1 39- S/ 1 <br />1 K 1 39- .S' c <br />39- 17,10 1 C z I <br />39- 1 <br />---IIIIIIIIIIIIIIIIII111111111111111111111111 111IIIy1111I1I1111I1I I1I11111111111111Ililllliiiiiillllilllll111111111 1111III111111 <br />1// T/= _ <br />1 J <br />I ( A y�iOU(S) DISAPDAM <br />TIONS) <br />; DATE ; <br />{ N 1 PLAN RevxewERB1 1�1� � 1111111111111111 I hTr� �����11111�11111111111�1111 1111 1111111111111 <br />APPLICANT MUST PERFOM ALL WORK IN ACCORDANCE RIM SAN JOAQUIN OOUNM ORDINANCES, STATE LAMS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN NUNTY, ENVIRONMENTAL HEALTH DEPARMENT. ONNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />PERFORMANCE OF ME WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT RNPLOY ANY PERSON IN SUCH A FANNER AS TO ' <br />BECOME SUaIECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACIOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES ME <br />FOL ING: "I CERTIFY MAT IN THE PERFORAANCE OF ME WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT IO 1 <br />COKPRNSATION LAWS OF CALIFORNIA." ///n/J%J 9 <br />APPLICANT'S SIGNATURE: /%eXYJ TITLE VC- ��0�%. At DATH� <br />----------------------------------------------------------------------------------------------------------------------------------- <br />BILLING INFORMATION: <br />THAT IN THE <br />WORKER'S <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 />(baa <br />Name �1�1 Address 3960 'NIL nnth sa. �gF e.4 Phone # I99-3999 <br />968 P5 x -a// <br />