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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3"D 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 />+------------------------------------------------------- ___ ____________ <br />EPA SITE M ------ <br />------T CONTACT i TELEPHONE - <br />+------------------------------ WCe �[o�-ac3-(oma <br />,,`^ ----------------------------------------------------------------------------- ------ - <br />F FACILITY NAME n I PHONE * Q, <br />I C ADDRESS �' l� t . 'Sit• <br />------------------------ --------- ___ <br />---------------------------------- <br />L CROSS STREET <br />I----------------------•------------1----- <br />T OWNER/OPERATOR------------------- <br />Y <br />-Y. .. , PHONE M <br />-T`Lc - V tQ <br />� <br />- __-C ICONTRACTORNAME. _ <br />PHONE. . <br />0 + --------4. .. <br />.. ... . <br />----------------- <br />N-------------------------`__�-------/�_'_-------__� <br />I CONTRACTOR ADDRESS (^ VO �` +`,` ,A _ Q C , L nA p�I�� ---CA LIC # t( j S1 g ( -CLASS a (%j / nrj�o <br />I T +---------------------- ------- Y ]".'..• _C. VJ 4/{ i x 1�'` CSC <br />R I INSURER q () �j • ___ �'--- ---___ -f ---- -- !( - <br />' A I-----------Ov`_'�C�_1LlU _ _ -_ i WORK.COMP.- '-I <br />C OTHER INFORMATION ---------------------------- , ��� b0 1 <br />' 0 ; <br />I R +---------------------- I PHONE p <br />r <br />__- <br />}__-rr,rrrrrrrrr rrr„ ilii -- , PHONE <br />------ <br />TANK ID k TANK SIZE l CHEMICALS STORED CURRENTLY/PREVIOUSLY 1 DATE UST INSTALLED <br />39- <br />I T 1 39- <br />A 39- <br />24 <br />N 39- <br />I K 39- <br />39- vv <br />39- <br />+---1 r „ „r ,lll„I„ <br />yy <br />.... ....... . <br />�� „ irrrir, i iirrrr <br />I L l PRO D K APPROVED WITH CONDITION(S) DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITIONS) 1� <br />l N PLAN REVIEWERS NAME (J �� <br />........ DATE <br />11l” <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 />...I . THAT IN THE. PERFORMANCE OF THE .WORK FOR WHICH THIS PERMIT IS I•SSUED,;- I, SHALL NOT EMPLOY ANY'PERSON IN,.SUCH ,A,MANNER A$ .TO <br />BECOME SUBJECT TO WOIIKER`S. COMPEN$ATION LAWS*.OF.CALIFORNIA'." _CONTRACTOR'S�HIRING�OR SUBCONTRA.CTINGSIGNATURE CERTIFIES THE <br />FALLOWING: "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: a U TITLE \410j -h Iaa, CC �_1�4C DATE-------------------------------------------------------------------------------- <br />--------------------------------------------------- <br />`T <br />—�� <br />, <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"ZlA V, WC5�CTU64PA' Address' 6 (i`,uu Au(, ; (`A Phone # 1{O�S-�(3--{�p`3IF <br />Signature l{j ctav <br />EH230038 <br />(revised 1/31/02) <br />