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SAN JOAQUIN COUNTY
<br /> ENVIRONMENTAL HEALTH DEPARTMENT
<br /> 304 E WEBER AVE,3RD 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 X PIPING REPAIRIRETROFVT _UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT
<br /> +---+-EPI, 6I^E_N___ ---------------------------------------CONTACT--------r. TELEPHONE
<br /> _4_-P /I E5 �- !!4 6J 4,7-ifx,400--
<br /> 1 - -
<br /> F FACILITY NAME A 12 PHONE a '
<br /> A ----_------------------------_---
<br /> I C 1 ADDRESS 25'775 A 25ohS 5---P_0 4�-------------------
<br /> I ------------------------------------------------------------
<br /> L I CROSS STREET w -
<br /> F
<br /> T OWNER/OPERATOR SP WE-57- 0045- PP_tb"V-S LLC. , PHONE a
<br /> Y
<br /> -----------------------------------------------------------------------------------------------------------------------------------
<br /> C ; CONTRACTOR NAME I +I1 / 515i�{s PHONE 11 7ly/5b7' 400
<br /> 0 +-------------------------------
<br /> - N ---- =-- --- --------- _ � 6 ---------
<br /> N ; CONTRACTOR ADDRESS CA LIC # I CLASS - -
<br /> T -J �3 Vit_ _s °- ------------- --4� _f4A?. c-i4
<br /> R i INSLFRER 1 WORK.COKP.NO2-00DOf1)503__
<br /> C 1 OTHER INFORMATION ,
<br /> T ♦------------------------------------------------------------------------------------+-------------------------------
<br /> O 1 PHONE 0
<br /> R +---------------------------------------------------------------•- +
<br /> PHONE R
<br /> ------------------------------------------------------------------------------------------------
<br /> TANK ID N 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 /> L
<br /> 9-
<br /> 39 L APPROVED APPROVED WITH CONDITIONISV DISAPPROVED
<br /> A {SEE ATTACHMENT WITH CONDITIONS)
<br /> N PLAN REVIEWERS NAME DATE
<br /> •_- „i ,,,i,,,,,, , ,i,,,, ,,,,,,i ,,, , ,.,,iii,, ,,,,,,, , ,,,,,,, ,, i, ,, ii, ,,,,,,,,,,,,,,,,,, , i , i,� � ii; „iiia,,,.
<br /> APPLICANT MAST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAMS, 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 TRIS 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 /> MORVEF."S COMPENSATION LAWS OF CALIFORNIA."
<br /> APPLICANT'S SIGNATLW: �� TITLE &H DATE 317-3
<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 parry must acknowledge this responsibility for the billing by signature and date below.
<br /> M 11- E,.IV IL_ f h 3 bJ. MEVJL-L E-- 5;
<br /> Name Address �,2r►,.av�_, CAel2k-4-s- Phone# 1/-1�5Z,744c,c
<br /> Signature
<br /> FH230038
<br /> (revised 1131102)
<br /> 1
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