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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALT //��}nn�$ PDARTMENT <br /> 304 E WEBER AVE,30.0 FL�AUp W, PH 1: 14 STOCKTON,CA 95202 2 7 1 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIA R(RIPING REPAIR PERMIT <br /> E, Lryrr <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE I111*A r_ � TE PERMIT TYPE BELOW: <br /> _TANK RETROFIT _PIPING REPAIRIRETROFIT_UNDER DISPENSER CONTAIINME T REPAIR/RETROFIT <br /> + <br /> EPA SITE # I PROJECT CONTACT & TELEPHONE # <br /> ERRE ____________ _ ERRE ERRE__ ERRE__ _____ _ _ <br /> P FACILITY NAME q 6'yc C•( PHONE # <br /> A +___________________ _�_J_ _ _ _______________________________________�_._'__A____/_________Q_______d4/p _----------------------- <br /> ADDRESS X22D ; <br /> C 3�J_�—___7Ls�_____l3__�(_ j____7_�rn 4.`.J____Se _____S_�_ v________________________ <br /> I ♦__________________ _ _ / 11 __ <br /> L ; CROSS STREET <br /> T 1 OWNER/OPERATOR PHONE # <br /> Y <br /> ___+____________________________ _____�/__________________________________________________+________________-__ ' <br /> C 1 CONTRACTOR NAME / 'J PHONE # <br /> O +______________DRESS D tI/-/, �� - _ _ CA LIC # WORK.COMP.N 3q�� <br /> � ln�-o{,LQ-- ---------- - ------------D----'------ ------------- <br /> N CONTRACTOR ADDRESS /I// e� � • /� -7 q'j l V CLASS <br /> �i ERRE ________S___------------------------------------------------------------ <br /> R <br /> _____________ ______________________________________ _ <br /> FINSURER �j".,__C__�__Ld - `-______________________..___________+___-____________________________________ <br /> C OTHER INFORMATION 1 <br /> , T + _________________________________________________+ERRE__ _______________________, <br /> 0 ; ; PHONE # <br /> , R +_____________________________________________________________________ ___+ERRE__ <br /> PHONE If <br /> _________________________-___-__-___________________________ ______--_ <br /> TANK IO # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> f, <br /> ; ;;; ,, XX..... <br /> L " "1 1 "APPROVED LAPPROVEO WITH CONDITION(S) „DISAPPROVED�� ' ' <br /> A -r` frSS BE ATTACHMENT WITH CONDITIONS) <br /> ; N PLAN REVIEWERS NAME IV. IY U DATE _?2,11-06 <br /> 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 SUCH A MANNER AS TO <br /> 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 <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE DATE <br /> --------------------------------------------------------------------------------------------------------------------------------- <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 Address Phone # <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />