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0 <br /> 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 REPAIRIRETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> ------------------------------------------------------------------------------------------------------------------------ <br /> EPA SITE #________________________________ PROJECT CONTACT-6_TELEPHONE-#_ w <br /> +----------' <br /> F FACILITY Lam' <br /> ; NAME 1 nn' t J__A -Q- ' PHONE # <br /> 1L J c <br /> A --____________________________________________ ___________________________________________ <br /> C ; ADDRESS 9 l VOCE IJ F(ri nJLC a J�- tlu L-i12 ------------- <br /> I -----------------'-- --------------------------------------------- ` <br /> L ; CROSS STREET <br /> T ; OWNER/OPERATOR (� PHONE # <br /> Y ' B W E-% Co AS' T,`� DVC—' C '114 - C,7o <br /> +---------------------------------------------- ----------------------------------------------------- - <br /> C ; CONTRACTOR NAME S.7W FA V IF 7- C A C PHONE # S0-�_V_ � S� <br /> l _"______________ _ ---------__ <br /> ' N CONTRACTOR ADDRESS CA LIC # 1 CLASS 1A H� <br /> �(� a H�. C�' 7 )►7=r------------------- -- ----- ----- <br /> R ; INSURER \ ( A J ; WORK.COMP.#4 J_7�Uu J 4lp3 <br /> JJJ --------------------------- -----1�s+ ` <br /> C ; OTHER INFORMATION ' <br /> ---------------------------'- <br /> O , PHONE It <br /> ---------------------------------- <br /> PHONE <br /> ____________________________PHONE # <br /> ________________________________________________________ __________DATE LST INSTALLED ____ <br /> TANK ID # TANK SIZE ; CHEMICALS STORED CURRENTLY PREVIOUSLY UST <br /> 39- <br /> T 3 9- <br /> A 3°- <br /> N 3 9- <br /> K 39- <br /> 3 9- <br /> 39 <br /> ..........��„ .11'Uy/u <br /> P Vt- <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE AT ACHMENT WITH CONDITIONS) <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 CF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFYTHAT IN THE <br /> PERFORM;UICE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY A69SON IN SUCH A MANNER AS TO � - <br /> BECCME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THa <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT:TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> .�.Y <br /> APPLICANT'S SIGNATURE: TITLE Q DATE Q <br /> +-------------------------------------------------------------------------------------------------------------------------- <br /> BILLING INFORMATION: <br /> Sf A" <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 owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name Address Phone# <br /> 1 <br />