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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3 R 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 REPAIPJRETROFIT UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT <br />EPA SITE # <br />F 1 FACILITY NAME <br />A +- --- <br />1 C 1 ADDRESS (et <br />I---------------- <br />L 1 CROSS STREET <br />1 I +_______________ <br />1 T OWNER/OPERATOR <br />Y <br />1 C 1. CONTRACTOR. NAME /4�tl- A <br />1 0 -_----------------------------- <br />1 N 1 CONTRACTOR ADDRESSa1 OV -TV <br />1 T +__---_ 9` <br />1 R 1 INSURER A Lt= T+ <br />' A--------------J!w�^__-Q__C <br />C OTHER INFORMATION <br />T------------------------------- <br />R <br />-_ _______________ <br />O <br />, <br />11 TANKI IDI«11 <br />39- <br />T i 39- <br />1 A 1 39- <br />1 N 39- <br />K 1 39- <br />39- <br />39- <br />P <br />1 PROJECT CONTACT 6 TELEPHONE # <br />- <br />._______________________________- <br />, u -.C. CSt64A ck0. <br />CA LIC # <br />PHONE-#- ao q - 41 2-- Ab O6 <br />1 PHONE ----- <br />-PHONE flp7-_ss _�sa tf .---, <br />=— $1P' CLO ----- <br />1 WORK.COMP-# W g A3SDT0 <br />1 PHONE # <br />I PHONE # <br />TANK SIZE 1 CHEMICALS STORED CURRENTLY/PREVIOUSLY i DATE UST INSTALLED <br />I L APPROVED V APPROVED WITH CONDITION(S) DISAPPROVED <br />1 A i y15E ACHM•PT WITH CONDITIONS)1 <br />1 N PLAN REVIEWERS NAME „ " ,,,,,•,,,,,,,, " ,,, DATE 4-c L, /Cf Cs <br />APPLICANT MOST PERFORM ALL W X IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE. PERFORMANCE OF THE .WORK FOR WHICH THIS PERMIT IS ISSUED;. I, SMALL NOT EMPLOY ANY PERSON IN :SUCH .A.MAWNEB A$ To <br />BECOME $UHJECT TO WORMER'S COMPENSATION LAMS 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 SMALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA. - <br />j �y� <br />APPLICANT'S SIGNATURE: } V1 (/t.C/" ' W TITLE �" ��awyt. "IIY�� DATE I � OIAJ71 <br />C <br />+_______________--________---_______---_-________-__________-_________-_______--____________y <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 />Name11JA.R'7nN V, U16GtEE!{A&J Address W Qaiuu Ame SS, ek 1QG'-Phone # 46%-90-406 8 <br />Signature��G <br />EH230038 <br />(revised 1/31/02) <br />1 <br />