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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 /> +--------------------- ------------------------------------------------------------------------------------------G---------------+ <br /> EPA SITE # : PROJECT CONTACT & TELEPHONE # M (CNA-" WALT-09 <br /> +------------------------------- ------------------------------------------- ------------------ ------- <br /> F ; FACILITY NAME CC - 44 F_L(_ PHONE # <br /> IA +--------------------`- --------------------------------------------------------------------------------------------------- <br /> C I ADDRESS ---------3�p O 0(LE-C.A'�D C-t- - S'Po C(L TGN . -- -- 9 - 2 ( Z. <br /> I +--------- - ------------------------------------------ ------ ------------------------------------------------( <br /> L CROSS STREET a W yN S�(L L x - ' <br /> II +--------------------------------------------- ----------------------------------------------------------- <br /> M C - <br /> 1 T I OWNER/OPERATOR ` A,-T A L e- PHONE # S(o - <br /> , Y i l <br /> --------------------------------------------------------------------------------------------------------------------------------- <br /> C , CONTRACTOR NAME V)A L T-0 4 G x c,(�E 1Zc K C - 9r b - 3 3 3 - i/ <br /> PHONE # ' <br /> ------ - - ------------------------------��--- ----g---------- ------------------------------I <br /> o <br /> N I CONTRACTOR ADDRESS---- Q .-$O�-�O Z�__W_S A�Lro CA LIC # 6 '� Z 3 F CLASS <br /> -------------- ----------------------------------------- --- ------------1 <br /> R INSURER <br /> A ' WORK.COMP. <br /> ----------------x-rk��---- �-------- }(3 0pQ 9--Z--�--0---- <br /> ' <br /> I C OTHER INFORMATION <br /> ' --------------------------------------------------+----------------------------------------I <br /> 0 PHONE # <br /> PHONE # <br /> --------------------- <br /> TANK IDf# TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED ; <br /> 39- m l S� 000 (�A.SOL(Aw <br /> T ; 39- D L $� 000 •� <br /> A ; 39- O 3 �� 00 d IE.LEL VG L. <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- I <br /> + y '1' 1""'1 " 1 I",_!APPROVED " APPROVED'WITH'CONDITION(S);," DISAPPROVED' <br /> A ,`_ S (SEE ATTACHMENT WITH CONDITIONS) <br /> LM <br /> N PLAN REVIEWERS NAME <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 CALIFO IA." <br /> APPLICANT'S SIGNATURE: ✓ I TITLE COµTR M-"(P(1-- DATE ( O b <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 /> Vjkc"1-0.{ (7. d . R0% (oif- q�b <br /> Name FA e, ( >L tv 2c Address S D-c-" C A 4?5'6 4( Phone # 3--3 - ►r r L <br /> Signature <br /> PU i cwt A-&-t- E- _ WA- C T—o 4 <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />