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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3TO FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> �J THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> /\ETRb FIT TANK RETROFIT _PIPING REPAIRIRETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +____________________________________________________________________________________________________________ _____ <br /> ____I`�_______ <br /> I EPA SITE N I PROJECT CONTACT 6 TELEPHONE K LO�t <br /> 1 -- F>zESNour�-��--- -fr_s_Sc'!o9.4 <br /> F 1 FACILITY NAME+ CI Q <br /> CZ1R _O____C_{_J --HONE - ��/� <br /> I I ADDRESS___ e SO____N____K/ _y ........ <br /> L I CROSS STREET HAR o/Aj/_ 1 <br /> I +________________ __ <br /> ------------------- -- <br /> I owxEn/oesRAToni PHONE s I <br /> Y tGto-r��r_eQ65T_-P_ �_Roa� ---:S �c�--------- aOq-&y933 S I <br /> 1 C 1 CONTRACTOR NAME I PHONE A l <br /> ID +----------- ---- -TA-I-T_---E_1434_------------------------------- ------------------------------------- 2 <br /> I T CONTRACTOR ADDRESS 1 CA-LIC b CLASS eiO <br /> I = $3 / p .2 o g------------- �t I <br /> 1 R 1 INSURER 'f�KK�- ��k_F_jF�I�T� --------- I WORK.COMP <br /> I A 1_______.. <br /> I C I OTHER INFORMATION <br /> O i____________________ _______________________________________________________________+___._ <br /> ___________________________________I <br /> IR +____________________________________________________________________________________ PHONE_-________--_____-______________-_ <br /> I I PHONE If <br /> +-^ilillllllllTANK lIIolp1111111111II---------------------------------------------------------------------------------------------- <br /> CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE USS INSTALLED I <br /> 1 f 39- ! I /SA3ry sxzs CHER"7 &Asot.-tAr� I <br /> I = 139- / B 4 <br /> I A 139-c /2anp r <br /> M 1 39 <br /> I K 1 ]9, <br /> I 1 39. <br /> +---hili li , fi iiillf fill lliill ' Iii 11111 Ili {,Ili it{, flllfl Illlllllilllf{{ III lifllilil illllllf illllfll{i l,ii{lilll , <br /> iP <br /> I L ' _ APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> l A I (SEE ATTACHMENT WLTH CONDITIONS) f <br /> I N I PLAN REVIEWERS NAME DATE <br /> ---Illllllllllllllllllllfll tli III 1 I L'I111111111f 111111 111, 111 Illi IIII1111 „ 111111111111IL'Ill 111!1 II ,I <br /> ' APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> 1 SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> 1 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 /> 1 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I <br /> I FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> 1 WORKER'S COMPENSATION LAWS OF CALIFORNIA.- <br /> i <br /> ��,�o�� <br /> { APPLICANT'S SIGNATURE: L�yAyrd'_ �//4J TITLE 4 �4&�ATE <br /> ^^ —p <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 /> NameAddress Phone # <br /> Signature <br /> EH230038 � <br /> (revised 1/31/02) <br /> , 1 <br />