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D <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEA304 E WEBER AVE,3LTHRDEPARTMENT)j� , �o�,� <br /> STOCKTON,CA 95202 p'V� <br /> � ^,-;,. <br /> �,v � ;c� 'A`�E,VTrgFA'tTH <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 BECI <br /> _TANK RETROFIT PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> ------------------------------------------------------------------------ - <br /> EPASITE # PROJECT CONTACT & TELEPHONE # <br /> +----------------A--n--A----v it <br /> -#- ---- ------------------------I <br /> F ; FACILITY NAME Awe #' 2 3-3 PHONE <br /> _# <br /> ----------------------------------- <br /> I ADDRESS �1 U8 8 E/JTp M hI f��L r 7�R• S l-L`CIC i t r�c Cly. ��5Ze 7 <br /> L 1 CROSS STREET <br /> , <br /> T OWNER/OPERATOR PHONE # <br /> Y ; 5P W 6s—i CoA,PQopua s L Le- <br /> -------------------------------------------------------- --------------------------------------------------------- <br /> C I CONTRACTOR NAME TAIL_r-?4 viQDUNC-rIT-S ySI�S------------------------------ PHONE # tl1�. ) �"7-1,L�0 ' <br /> 0 +-CONTRACTOR ADDRESS '0//3 �.N�,(i�r C,/.j-0 � __ U_S---I-CA-LIC-#S��.Ot�k---------CLASSA A,S13_N-AZB_e-lo; <br /> � <br /> R INSURER PA Kv C' uA r-_N_�Z-�`'�s-'---------- apt WORK.COMP.#MC 10ex I6pSGL -- ---' <br /> C OTHER INFORMATION <br /> T +-------------------------------------------------------------------------------------- <br /> , <br /> 0 PHONE # <br /> R +-------------------------------------------------------------------------------------- <br /> , <br /> , PHONE # <br /> ---------------------------------- ------------------------------------------ <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T 1 39- <br /> A ; 39- <br /> N ; 39- <br /> K 39- <br /> 39- <br /> 39- <br /> +--- , <br /> P <br /> L APP OVED APPROVED WITH CONDITION(S) DISAPPROVED D <br /> A ( E ATTAC WITH ONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <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 �q tip CALL(. DATE �'zy <br /> l7 <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 /> TAIr C-4vi2crNc;q7u(, <br /> Name 5 y5[54s Address 143 j,1. t,1FV1u.E 5i..0 o�za,,t6t qzk(,s'Phone <br /> Signature , ilei_ <br /> J <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br /> 5 <br />