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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 /> _TANK RETROFIT 3( PIPING REPAIR/RE+RGW UNDER DISPENSER CONTAINMENT REPAIRIRET-R9 <br /> ____________________ _____ <br /> I EPA SITE k 1 PROJECT CONTACT 6 TELEPHONE k <br /> ____________ <br /> ___ _________ <br /> F I FACILIT-------Y NAME -_�r►Q C A,� PHONE k f _-_i <br /> A +- nw/4t�p11]_L/_Cees i;G�p_ a �� .s------------------OW Ylr _335 <br /> I + ADDRESS ____� li _ 'v __ _ /iI[w{p ____ .l_ I <br /> L CROSS STREET ________________________________ <br /> _____________________ <br /> I +--- ---------------------------------------------------------- <br /> I <br /> _ '�� l� _____✓_Y_sd <br /> I T I OWNER/'14-'-"'""- /04k.4 <br /> `� HONE k <br /> Y I ODc74k. y t .yamJ/� I P <br /> 1___+________________ _ ___ __ 1 IQ _ YJ O r_ JiJGc!________________ ------------------------ <br /> _ I <br /> I C I CONTRACTOR NAME • I PHONE k _____i <br /> Lam.F._ �t`i� Q/t� u_ fQ�Y _ ------ ----- -�0�=,•?�3'� , Dc <br /> I D +------------------ Q j ry f� <br /> N I CONTRACTOR ADDRESS //�_+_-�_C___ `•__r ,ft_z .�---Qo___!_`"_'_' ° ko_'�.43_�l D__---I--`ti'_,ssa,.�,.�$,_ea;tFa_i� <br /> T +_____________________ _ a-± <br /> R I INSURERI WORK.COMP.k <br /> A "2 .-------------- ------------------i 15.9.12G_LO% <br /> e o <br /> I C I OTHER INFORMATION -- ---------1 <br /> O ------------------------------------------------ <br /> _____________________________________i PHONE_-____ ____________________________i <br /> IR +____________________________________________________________________________________+________________________________________1 <br /> ---� PHONE k 1 <br /> + IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII-------------------------------------------------- ------------------�_____________________ <br /> 1 1 39- TANK ID k T CSS IZE i CHEMI STORED ED TLY PREVIOUSLY I DAT S INSTALLED <br /> I T 1 39- I (/ i--� � <br /> K 139- I <br /> I 1 39- <br /> 1 39- 1 <br /> P �1111111111111111111111111111111111 11111111111111 1111111111111111111 11111111111111111111111111111I1111111111 11 <br /> 1 <br /> I L APPROVED _ APPROVED WITH CONDITION(S) _ DISAPPROVID 1 <br /> AATTATfuITH CONDITIONS) <br /> N I PLAN REVIEWERS NAME Q lj_f/ ,{�A i ..� Y� DATE <br /> 111111ililillil1111111 1111111111 ITI III 111111III 111HII 111111111 111 1111111 I 1111111111 11 I 1 IIIIh iiHiH l <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF 1 <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 /> 1 <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> I WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> i <br /> 1 ' <br /> APPLICANT'S SIGNATURE: TITLE a11171A, 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 /> 4 <br /> EH230038 <br /> (revised 1/31/02) T Y <br /> 1 <br />