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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3AR FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM i THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> _TANK RETROFIT YYIPING REPAIR/RETROFIT,,,UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +_______________________ ________________________________________________________________________________________ <br /> EPA SITE p - PROSECT CONTACT i TELEPHONE X M 1Al2LUM slrtp-�tJ /.as <br /> i F i FACILITY NAME �. L _ Tµ� . _________________ IT PHONE p _ O q _ <br /> 1 l <br /> 1 A +_________________ ____ _ _ _________________________________ 'Z�! IDO� <br /> i <br /> ____ <br /> I C "DRESS //11�.(/.-r-�_____�l•-C"_ -- <br /> _ _ _________________________________ <br /> ' L I CROSS STREET _______________________________________________r <br /> r <br /> r , <br /> , I h <br /> T i OWNER/OPERATOR ���. _____HONE_____________�.-________________ <br /> N <br /> Y I, <br /> .: " NN <br /> I C 1 CONTRANLOR1NAME. . 3. .. .. <br /> 1 0 t_____--__._,_______ _ . <br /> 1 N 1 CONTRACTOR ADDRESS ��Lt. ^. ^ ' 7J _ <br /> T t____________________ ____________ _ ____ _ _ _ G LIC p Q\�G I,�L�_________CLASS�J�}-C(Q �_1 <br /> 1 R 1 INSURER l� LL'�O� ��� Y -(1nc�� ry __ ________r_ _ ______ E p �j� <br /> 1 A 1___________ _______________�mo WORK.0----- --`TAJ^SO O <br /> 1 C 1 OTHER INFORMATION iv +---- ----------- - - - <br /> 1i T +_________________________ ' <br /> 0 _________1 <br /> i R +__________________________ 1 PHONE p 1 <br /> ----------------------------------------- <br /> PHONE p <br /> t___111111111I L'1 L'L'IIII;III;IIII 1;____________________________________________________________ <br /> __________________________________1 <br /> TANK ID p TANK SIZE CHEMI GLS STOR ENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> 1 T 39- <br /> 1 A 1 39- <br /> 1 N 1 39- <br /> K ' 39- <br /> 1 39- <br /> 39- <br /> +-p- rr ,,,rrr�......... <br /> L PPROVED V APPROVED WITH CONDITIONS) DISAPPROVED <br /> N PLAN REVIEWERS NAME A WITH CONDITION6) <br /> t---„„ „rr ,rr ����r r, rrr <br /> ,�ur.r„.r ��,rrr� �r ..........,r.......... rrrr illi 11�1,,,r„ <br /> APPLICANT MUST PERFORM AL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY <br /> .THAT IN THE.PERFORMANCE OF THE MORK FOR WHICH THIS,PERMIT+IS FSSUSD�.I,6NALL NOT HMPFAY ANY'PERSON IN NOCK.A.MANNEH AS .TO.', . <br /> BECOM6 SUB�7ECT TO WOR1tEh''3. COMPFU1SATION IAWS.OP.CALIPORNIA'.N .CONTAACTOILr S�HIRING OR SUHCONTRACTING.SIGNATURE CERTIFIES THE - - -- - <br /> . 1 FOLLOWING: •I CERTIFY THAT.IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I'SHALL EMPLOY PERSONS-S1U9JECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA.. <br /> cp-ctG�� U. c e w t ('�p,� /,� qq��yy�� <br /> i APPLICANT'S SIGNATURE; TITLE t OLIALLC'L OTIAYYOATE tV t� L , <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 140-v{ff4LV, LJJ%Wk 4ALIWI Address b$0 QSikOL Au4- , SA CA. Willa- Phone # ``108-1(3-403Q <br /> SignatureZ-L. V—A ,-moi , , <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />