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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3RD 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 REPAHURETROFIT <br />EPA SITE # ! PROJECT CONTACT s MI,RPHONH # s65yr covet - 951-509;7-5110 <br />P 1 FACILITY NAME ] ELLo <br />A+____________ <br />; CADDRESS <br />I . ; 5 3 -------- <br />L1 CROSS STREET <br />f <br />I+__________________________ <br />T ! OWMSR/OPERATOR yE4,ota <br />Y <br />26I&A <br />cADex0 WA <br />Faemv47 <br />C: CONTRACTOR NAME -FA14t <br />0 +------------------------------------------------ <br />N ! CONTRACTOR ADDRESS IDOL E 6H IRA ICC <br />T+_____ _______ _________________.`____ <br />R : INSURER V��Gherrck Sor PW-, urE< <br />, A ______ <br />C OT[BD2 INFORMATION <br />T + <br />O <br />TANK�ID!p�� <br />39-WAfL OIL <br />T ! 39- W STC OIL 1 <br />A ! 39- A ATI FREEI.E <br />N 1 39- hEA¢ OIL <br />K 1 39- MOTO¢, DIL <br />39- WASTE OIL 3 <br />39- <br />SIZE <br />PHONE # Z09 - 283 - 1300 <br />PHONE 4'3-3NL1-3 <br />PHONE # 9 51 — W 9'4 <br />UZ , CA: CA LIC # 1?603 =ILvS : CLASS A <br />; WORS.COMP.# <br />PHONE # 104 -, <br />____________ <br />PHONE # go9 — <br />,-(DIS) <br />9-<,�oSB <br />STORED CURRENTLY/PREVIOUSLY I DATE <br />I P <br />1 L ! APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br />A! I' (SEE ATTACHMENT WITH CONDITIONS) <br />N : PLt(1 <br />AN REVIEWERS NAME _ `— DATE <br />APPLICANT MOST PERFORM ALL WORK IN ACC)RDAN WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AG@1T'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 SUCH A WANNER AS TO <br />BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.^ CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING: •ICERTIFY THAT IN T 8 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWE <br />OF <br />LAFORNIA. • .y �� ,� L <br />APPLICANT'S SIGNATURE: TITLE Ptdl /• NAN AVa>SC(1C DATE <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 />cit GO v G Y Address3 t9 0 M"&5IgA ,s, 8 IS I Phone # It S I <br />11 Ak izI JcS.< I L' C- , cA g2s'o�-, <br />Sig <br />EH230038 <br />(revised 1/31/02) <br />1 <br />