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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 REPAIRIRETROFIT <br /> +------------------------------------------------------------------------------------------------ --------------------------------} <br /> I EPA SITE # 1 PROJECT CONTACT 6 TELEPHONE # <br /> i F i FACILITY NAME Q PHONE # ' <br /> IA --------------------- ----------------------------------------------- - � _Mti <br /> ' c <br /> I ADDRESS \^�V S�- �- <br /> L I CROSS STREET -T-- GS� � ��'o-ry,P <br /> i <br /> T 1 OWNER/OPERATOR ; PH # ' <br /> i <br /> Y <br /> i CI CONTRACTOR NAME PHONE # <br /> I0 +----------------------- �` ----- <br /> II N I CONTRACTOR ADDRESS IR( 45_R - CA LIC # -7C0 1 S5 : CSS 4 16 C to <br /> T +---------------------------� - -----------f------ <br /> R <br /> F <br /> 1 INSIIRER CE -.1. N T _ / ----- WORK.COMP.# <br /> C ; OTHER INFORMATION <br /> i <br /> 0 ; I PHONE # <br /> PHONE # <br /> --------------------------------------------------------------------------------------------- <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/P VIOUSLY I DATE UST INSTALLED <br /> I 39- 1 1Z�E <br /> T 39- <br /> I A 139- - ra <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- _ <br /> -11111 i <br /> L i "APPROVED 1 rrX APPROVED1WITH CONDITION(S)' _ DISAPPROVED <br /> P <br /> N i PLAN REVIEWERS NAME N 1 (SEE ATTACHMENT WITH CONDITIONS) D TE <br /> APPLICANT'MUST'PERFORM ALL WORKI IN1 ACCORDANCE'WITH SAN JOAQUIN COUNTYI ORDINANCES,'STATE'LAWS, AND RULES'AND,REGULATIONS1 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 6 L Q <br /> i <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 ` W Address x%4p,!S ,,,«�,— 1�.,,.,r►F•, Phone #(1614,3r,--�-�� <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br />