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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3i0 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 Y P+PfhIe REPAIR/RETROFIT ___UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +----------------------------------------------------------------------------------------/-----c---t--------------------------------- <br /> 1 EPA SITE # 1 PROJECT CONTACT & TELEPHONE # �// L�jiA17 / // J��_ j� <br /> F ' FACILITY NAME / <br /> A +_________________ _ _ T__iC _# D D__�j__________ PHONE-- /�-- ------- <br /> C 1 ADDRESS __�/V J���� /J__ __ _� <br /> L 1 CROSS STREET / <br /> . I y_______________' <br /> __V__ _____________ _ _______ <br /> _ __________________________________________ <br /> 1 Y OWNER/OPERATOR �gCGCM ����/-y �� i PHONE # <br /> ---•- -------(�l- ` C� S� f (/��J��X�` 1Z��-vi7�Z�7Q?---------------------- <br /> ---------------------------------------I <br /> C 1 CONTRACTOR NAME 1 PHONE # 1 <br /> I <br /> I <br /> N 1 CONTRACTOR ADDRESS i CA LIC # I CLASS <br /> I <br /> IT -______________________________________________________ , <br /> R INSURER 1 WORK.COMP.# <br /> A1____________________________________________________________________________________ - ____1 <br /> C OTHER INFORMATION i � <br /> 0 i 1 PHONE # <br /> PHONE # <br /> ______________________________________________________________________________________________I <br /> 11111111111111 <br /> I <br /> TANK ID # TANK SIZE 1 CHEMICALS STORED CURRENTLY/PREVIOUSLY 1 DATE UST INSTALLED <br /> 39' i ��ErOQ i i - <br /> I I <br /> 1 A 39- <br /> I N ' 39 <br /> K 39- <br /> 39- <br /> 1 <br /> 39- i <br /> y---II II11 1111111 11111111 II 11111 1;111 .1111 111111 1111111111111111111 111111111 III 111 111111 II 111111111 <br /> IIIIIIIIIIIIIIIIIIIIIII111111111111111111 111111111111111111111111111111111111111111111111111111111111111111111111111111111111 <br /> P . <br /> i <br /> L � APPROVED APPROVED WITH CONDITION(SIX DISAPPROVED <br /> A (SEE ATTA TH CO O 1 <br /> N PLAN REVIEWERS NAME��� DATE O 1 <br /> 11 II 1 1111111...1111 II I I I 11111 1111 11111 111 . III 11;11 .11111.1. 111 11.1..1..1111111 .. 1 <br /> 1111111111111 II 111111111 .11111. 11111111111111111 111. II II II 11..1.1 I1 111111111111 1 111111.1111111111..11 <br /> 1 <br /> 1 APPLICANT' MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCESI 11 <br /> , LAWS, AND RULES AND REGULATIONS OF 1 <br /> I <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGE'NT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 1 THAT IN THE <br /> PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPIAY ANY PERSON IN SUCH A MANNER AS TO ' <br /> 1 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'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 1 WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." 1 -- <br /> I 1 <br /> ' 1 <br /> r 1 <br /> J J <br /> APPLICANT'S SIGNATURE: TITLE <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 owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name ---------Address __Phone#_______,_ <br /> 1 <br />