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lu, lu, uu< :J. ,o tYJ7�Faai4s3 r1F IH FLUUR PAGE 03 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,Y'FLOOR <br /> STOCKTON.CAA 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 REPAIAIRETROFIT <br /> +------------------- _ <br /> i I EPA SITE q ( PROJECT CONTACT & SP--NE- / i IPT- 31a.'--------------^•••---* <br /> I ----------------------------------------------- TE- --- ---- b - .q-ik � <br /> I s ' FACILITY NAME Pz co PHONE f< <br /> —-- -,-....- -- - I <br /> I A +----------------^' j 7-6101. <br /> --------- <br /> L I C405S STREET' 'P, ______ <br /> I --------------------- ------------------,-----------------•-- <br /> T OWNER/OP&RATOR --- PtIONS ,•••- --- "I <br /> -Y-+ -- - h�esi---Coas-f-__PFco_Q�?G-T=S-_ �_LC.-----------------1-31.1-9-47D--s-4f-ii <br /> I C 1 wxrRnczOR MME __LL," �- --- -- - <br /> �TLON T-eck,-,010s� - -- <br /> I o --------------------- ------------------------ <br /> PHONE - 3i . 6 ��� <br /> I N I corrrRArros ADDRESS t�-�----)----�-�- -- ----------•--�----�-----------------I <br /> Are ICA LTC! - 6�sgq-- �s I <br /> R I INSURER -��1`-- �Gt I WORK.MMY <br /> I A I---------------- - - ----- ---- - --- --- - - - - - - --------------------------------------- <br /> C 02 (, F�4 co 63s",1 <br /> I I OTFIER INPOWmTTON --' <br /> C ' <br /> _________________________+----__________________________--- <br /> I____T ------------------------------------------------------------ <br /> 0 1PHONE <br /> R +------------------------------------------------------------.________ __-.__---I ----- N <br /> PHONE 0 <br /> + IIIII IIIIIIIIIIII!IIIIIIIIEIIII------------------ -------------------------------------------_......_-__-_ <br /> I I TANK TO p TANK SIZE I CHMICAL$ STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLRD <br /> I 139- <br /> I I <br /> N — <br /> I x <br /> I I I <br /> 1 I I9- I <br /> i I <br /> --1IIII J II =APPROVED <br /> L APMVED _ CONDSTION(S>/17 DISAPPROVED <br /> T A CTRgSil WrTH CONDITIONS) <br /> i <br /> N I PLAN UVIEW2RS ZIAtlT DATE <br /> -•'111111!Illliilill111illllllllllllllllllllliillli, lil lllllllll 111iIIIliIIIIIIIIIIIIIIIIIIIIIIIIIIIIIiIIIIII�IIIIiIIIIIIIIII <br /> I I <br /> APPLIfANT MUST PERFORM ALL WoRx IN ACOMMANCE WITH SAN .IOAQUIN Ooturiy ORDINANCE;, STATE LAWS, AND RULES AND REG(ILATIONS OF ; <br /> SAN JOAOUIN coumT, ENVIRONlmr=HEALTH DEPARTMENT. OMM OR LICENSED AC&NT'S SIGNATURE CERTIFIES THE FQUQ MING: •I CERTIFY I THAT in THE <br /> oFiiiF MWCE OF THE WORK FOR.WHICH THIS PERMIT IS IssUED, I SHALL NOT 3GLOY ANY PERSON IN 3UCE A MANNER AS TO <br /> 95=S SUBJECT TO W01KER'S CONPENSATION LAWS OF CALIFORxIA.• CONTRACTOR'S HIRING OR SIIHCONTRACIING SIGNATURE CRRTIPIES THE <br /> ' POLM,OWINC: •I CERTIFY THAT IN THE PERFOF&WCE OF THE WORF FOR WHICH THIS PERMIT IS ISSUED, I SHALL ENPiAY PERBoNs sUa7SCT TC ! I WORLM <br /> 03MPENSATIOM LAWS of CALIFORNIA,* ! <br /> I I <br /> I I <br /> I <br /> ' APVGICAPT'S SIGNATU4E: TITLE VPDATE II ( 2 <br /> -------------------------------------------------------------------------- <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 owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name_—_ —^� (,; —Address___ ---Phone# <br />