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r <br /> ' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3RO 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 REPAIR/RETROFIT ------- <br /> PROJECT <br /> _________________________PROJECT CONTACT 6 TELEPHONE #____________________________�� -3-- ! <br /> ________________________ ��,,JJII 11 ____"1��1""lll <br /> I EPA SITE # I �A�__ UN_��_1��K__ ___ ______________I <br /> P I FACILITY NAME-A�,CL) }�M1pf11 I PHONE # _________________i <br /> _ _ ___________ ________________________________________________________________________ <br /> CI ADDRESS 1iJ (�___4^!_------ ------------ i <br /> ________________________________________________________________________-_____ <br /> { L { CROSS STREET H �T ` (� <br /> { It-------------'l-f'�Q O_1�.�----- --------------- { 1 �.v�Q Ull--------------I <br /> ---------------------------------------------------- <br /> { T I OWNER/OPERATOR I PHONE # q <br /> { Y I ( �_I, ST_CJASl �NS��` �5� �C---------------------------- •1 -- ,4 —�`� I <br /> l T I .,I�AI , qv—� s <br /> C { CONTRACTOR NAME AU ------------- <br /> .... _PHONE #---��_ -------Q-------------i <br /> I Q --------------------- II n C L `,A n �L <br /> I N I CONTRACTOR ADDRESS _ gI (,Un1,�JU-( Y>l1¢ S\C�(.��}�_ \4 JyC•L I CA LIC #I�`l'��_________�_ SS'=VR!'L�`J.W-I1JC_____i <br /> R I INSURER ____ __L�_Q_ { WORK.COI�_R4�22!`_�'_•_SJ—0-- -------i <br /> AI__________ __________________________________________________i________ <br /> { C { OTHER <br /> I INFORMATION ___ <br /> ________________________________________________I <br /> T <br /> PHONE # I <br /> IO { ________________________________________I <br /> Rt_________________________________________________ PHONE # <br /> I __________________________________________________ <br /> i___iIII {I{IIIITANx IDiIIIIIIIIIII{i----- <br /> TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED <br /> I 139-T 39- <br /> I <br /> { A 139- { <br /> T N I 39- I <br /> K 39- <br /> 39- <br /> 39- i I <br /> I {IIIIIIIIIIIIIIII IIII IIIII II Illlll{iilili111 Ili HiMi lliilll I I I Illllllllll . Illl IIIII { illi IIIIIiiilli <br /> P <br /> L ` APPROVED APPROVED WITH CONDITIONS DISAPPROVED I <br /> A { ( ATTACHMENT WITH CONDITIONS) <br /> N I PLAN REVIEWERS NAME DATE <br /> "III {IIIIIIIIIIIIIIIIII II I i i II II Illi 11I <br /> 11 IIII IIIIIIIII {IIIIiiIIII Illiiiiiliil <br /> I <br /> S OF <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONI <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> I 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 I <br /> I FOLLOWING: 4 CERTIFY THAT IN THE PERF CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SRA,L EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPINSATION LAWS OF CALI I / �I I <br /> I TITLE <br /> AG Ekr DATE L1 S <br /> { APPLICANT'S SIGNATURE: t <br /> --------------- <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 /> /� ��A�,r,a DQ <br /> Name� N IN u'f —, Address SAGA A aAG/A C C k Phone # � t3jO 3F/2 <br /> Signature 'e6: <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />