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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3" 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 REPAIRIRETROFIT <br />+--------------------------------------------------------------------------------------------------------------------------+ <br />EPA SITE # ; PROJECT CONTACT & TELEPHONE # <br />-----------------------------------------------------------------------------------------------------------------------------I <br />F ; FACILITY NAMELLl ' PHONE # <br />A +----------------yj----14(0- -----W � --- X1 1 A----------------------------q- <br />-R ------------ <br />S�------------- <br />' C ; ADDRESS <br />I+---------------� (z 44 __El�'� �A &.�o��r� ----�R ----------------------------------------------------------- <br />L ; CROSS STREET <br />T ; OWNER/OPERATOR ; PHONE # <br />Y <br />---+---------------------------------------------------------------------------+----------------------------------------' <br />I C I CONTRACTOR NAME I- �%, ;-PHONE # ' <br />0 +---------------------------------=----------------------------------------------------------------------------------------I <br />N CONTRACTOR ADDRESS I -7 ^7 5 q--- fVrroe G U--------I-CA-LIC-#-- 6 �'L �((-1-----CLASS-- A - -- d�---- <br />; T +-CONT---------------- J .Z L 5.15..._ ,J <br />' R INSURER r-� �I Ate/ , WORK.COMP.# t "7 g 7 099 q -5-- <br />A ' <br />G------�F€T-------------------------------------------; <br />C ; OTHER INFORMATION <br />0 ; ; PHONE # <br />I PHONE # <br />---------------------------------------------------------------------------------------------- <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />T <br />9-T 39- - - - <br />A 39- -- - - <br />N 39- <br />K I 39- <br />--- <br />39- <br />39- - <br />ZROVED <br />P ; <br />L ; APPRO ED WITH CONDITIONS) DISAPPROVED <br />A ; (Sfi TTACHMENT WITH CONDITIONS) <br />A�zk) <br />N ; PLAN RSVIHWHRS NAME DATE <br />QUO <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 />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 <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 />WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />r <br />APPLICANT'S SIGNATURE: _ � Sack TITLE <br />BILLING INFORMATION: <br />DATE <br />------------------------------------------+ <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 M11Z-67 b 0 77Z, -A-) Address 1-,' 7 `t Q t% TT77X2C c, %' Phone # -20q-S32--73,2,o <br />Signature <br />Eevised / dvJ <br />(revised 1/31/02) <br />1 <br />