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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3"FLOOR <br /> STOCKTON,CA 85202 <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 REPAIRIRETROFIT <br /> '- - - --- <br /> EPA SITE 0 PROJECT CONTACT 4 TMEPHONR # <br /> -------------------------------- s;d_+ T�nlv�� � �o------------- <br /> 7 <br /> 112 <br /> F FACILITY NAME PHONE C-�^"- PHONE 0 '(CA - - 1 <br /> A +--- ------- q og ----------- 33----- -- ------------ ----- ------- -� �. , <br /> C ; ADDRESS - <br /> I + ------ ----------------�-� OSJ -_'.,---_ -0 LS' _`2k. lr--_-------- ---_... ..-----------_ ----------_------- <br /> L ; CROSS STRBBT � <br /> 3 ---------------- _ 1�.'-Y v�.GV:I17ic-J----,.. -------------------------------------------------------------------_.-__. <br /> T OWNER/OPERATOR PHONE # <br /> Y ' <br /> i C -(-TRACTOR HAKR t f'\ _-- PHONE <br /> ---- ___ -i- � i_-__ � - -- - L-5_�C-;-) G% <br /> CORMACTOR <br /> A-DORMS <br /> Z ---------- ------- C- t Ct_ � �a�-t - ------------- <br /> R <br /> INSURER <br /> ---------------------RIfCONPg <br /> _ _ _ ____- <br /> C OTHER INFORMATION <br /> T ------------------ --------------------------------------------------------------- -------------------------- <br /> PHONE <br /> ------------------------PHONE ii <br /> R --------------------------------------—-------------------------------------- --------------------- . <br /> PHON9 M <br /> ----------------------- ------------------------ 11- -------------------------------------- <br /> � TANK IDS#-- TANK SIZE CKHMICAL9 STORJ O CVR:RHITLY/PRBVZOUSLY ! DATE VST INSTALIII,R <br /> 39- � _ : 12-_ CX_X? . <br /> AN 39- <br /> t ice. t <br /> K <br /> 39- <br /> .. . ,. .. <br /> L APPROYSD APPROV3M WITH CONDITI0II153 DISAPPROVRD <br /> A .�.— /SRH ATTACHMENT WITH CONDIT=ONS) <br /> F ; I PLOW REVIEWERS !JAMB DATE V _ I-00 _ <br /> APPLICANT Mibi' PERFORM ALL WORK ZN ACCORDANCE WITH SAID JOAOVIX COUNTY 0RD1MANCES, STATE LAWS, AND RULES AND RROULATIONS OF <br /> SAN JOAO= COUNTY. ERVIBOB4WTAL KEALTr DEPARTMENT. OFRJER OR LICENSED LWRNT'S SIOMATURE CBRTSFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THB PERFORMANCE OF THE WORK FOR NHICR THIS Pamir I9 ISSUED. i SHALL NOT E?IFLOY ATJY PERSON IN SUCH A MAHMSR AS TO <br /> BECCMfi SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.• CONTRACTOR'S BIRMO OR SUECONTRACTTNG SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CESCTIFY THAT IE THE PERFORK46ICZ OF IRE WORK POR WBTCH THIS PERMIT IS ISSUED, I SHALL BMPIAY PERSONS SUBJECT TO <br /> WORKER'S CDHPEESATIOW LAWS OF CALIFORNIA.• <br /> APPLICANT'S STOlDI - TITLE '! J'�-k DATE �© d <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 /> Names Lt� zt> >� .�> :1 Address C"1c-- �3 ;�,� -L , Phone -Cl) 2�15--; -21�z� <br /> Signature <br /> EH230038 <br /> (revised 1/31102) <br /> 1 <br />