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00 Il <br />SAN JOAQUIN COUNTY D2�33C EE v/�� n <br />ENVIRONMENTAL HEALTH DEPARTMENTOCT 2 3 2003 <br />304 E WEBER AVE, 3RD FLOOR <br />STOCKTON, CA 95202 ENVIRONMENT HEALTH <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT PERMIT/SERVICES <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 />-------------------------------------------------------------------------------------------------------------------- -----4 <br />------- <br />I EPA SITE # I PROJECT CONTACT & TELEPHONE #La <br />a <br />+-------------------------------------------- <br />I <br />F 1 FACILITY NAMELac Q <br />/�/\ <br />IA +------- .t�-..'... sr -.-r, --'h -;`----------------------------------------------------- <br />- __ --- <br />1 PHONE # <br />4.` <br />C I ADDRES'� <br />L I CROSS STREET <br />ALN2__ a 4-A?--------------------------------------------------------------------------------------1 <br />------------------------------------------ <br />i <br />I T 1 OWNER/OPERATOR <br />L., EST C -RST Pn,ao.,V�s <br />I PHONE # <br />I r)1A -(Or7o- 5300 <br />-Y-�--------------QP__ ---��-C--------- ------------+----------------- <br />C CONTRACTOR ,. W AvNt CQ�V A GT!S <br />o+--- <br />---------1 <br />1 PHONE # 5 (Da - ��D � 4 S 9 <br />i <br />-NAE <br />- ----------- <br />- ------------------------------------------------------------------------------------------------------ <br />I ------- <br />NI <br />N CONTRACTOR ADDRESSl(S ( Lj n " " �I CA LIC # , ` C <br />±li.�- r------- ��----�-1- 1-3 ' AjL 34- <br />-----------A ------- <br />R I INSURER _-FT1 u A <br />--LASS <br />_ 1 <br />------ --- -- ----I <br />WORK.COMP.# -7 00-VQaQe <br />c► --Vii- 3 <br />-IF <br />I A ---------------------------------------------------------------- -------------+------------------- <br />----1I <br />I C I OTHERINFORMATION <br />I <br />------------------------------------------------------- <br />— -- <br />I 0 1 <br />1 PHONE 1 <br />---------------------------------------------------- <br />_# <br />---------------------------------I <br />I i <br />i PHONE # 1 <br />+- -iii{Ii{I{IiIiiIl{iI{iiili{I{{III--------------------------------i----------------------------------------------------------- <br />__I <br />TANK ID # 1 TANK SIZE I CHEMICALS <br />STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED <br />1 1 39- <br />T 139- <br />I A 139- { { <br />I I <br />N I 39- <br />I K i 39- <br />9-39-39- <br />39- <br />39-_ <br />+ �II111IIIIIIIII11I I11I1111I 1111111111111111111111111 IIIIII IIIIIIi IIIIIIIII II, <br />PI <br />1IIIIIII II IIIIIIIIIIIIIII 11111111111111111111111 <br />1 <br />L 1 APPROVED WI CONDITION (S` <br />DISAPPROVED 1 <br />7RO <br />A I i1 - (SEA Tr ENT ; CONDITION <br />1 <br />_ <br />�.1 I <br />I N I PLAN REVIEWERS NAME <br />DATE <br />+{IiIII{IIiiIIIliliiilliiiili{{illiil{{ill 11 11 1111{ii{' II1iiIIIIIII{ill{{iI{iili{iI{{il{{ <br />illii 11111,1111111111111M I <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF I <br />SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY I <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 I <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 I <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." ' <br />I <br />I I <br />I � <br />I <br />APPLICANT'S SIGNATURE: �_v TITLE AGF t` T- DATE----------------------------------------------------------------------------------------------------------------------------------- <br />I O a Owl <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 .At,, ASE ti iF Address)3)(4L,. T I-I(eb Std L•41;cA `ion Phone # a13 -44 .311 <br />Signature <br />EH230038 <br />(revised 1/31/02) <br />