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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3RD 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 />1 EPA SITE # I PROJECT CONTACT & TELEPHONE # <br />------------------------------------------------------------------------------------------------------------------------------ <br />F 1 FACILITY NAME 1 PHONE # <br />{ A+-----------------------------------------------------------------------------------------------------------------------------1 <br />i C i ADDRESS <br />r <br />I L I CROSS STREET <br />1 I +------------------------------------- <br />1 T ; OWNER/OPERATOR ; PHONE # <br />Y <br />--------------------------------------------------------------------------------------------------------------------------------- <br />C 1 CONTRACTOR NAME I PHONE # <br />1 N 1 CONTRACTOR ADDRESS 1 CA LIC # 1 CLASS <br />' T+-----------------------------------------------------------------------------------------------------------------------------1 <br />1 R 1 INSURER I WORK.COMP.# <br />1 C OTHER INFORMATION i1 <br />' T +------------------------------------------------------------------------------------+---------------------------------- <br />1 0 I 1 PHONE # <br />PHONE # <br />---------------------------------------------------------------------------------------------- <br />TANK ID # rr���rrrll <br />TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOIISLY DATE UST INSTALLED <br />39- <br />T 1 39- 1 <br />A 39- <br />1 N 39- <br />1 K ; 39- <br />39- <br />39- <br />+--- <br />P <br />L ; APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />1 A (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <br />i <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 />APPLICANT'S SIGNATURE: TITLE DATE <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 <br />Signature <br />EH230038 <br />(revised 1/31/02) <br />dress <br />Phone # <br />