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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3'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 /> V TANK RETROFIT PIPING REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +------- -------------------------- -----------------------------------------------------------------------------+ <br /> EPA SITE # PROTECT CONTACT & TELEPHONE # _-W r>eP" 'gA6�y <br /> ----------------------------------------------------------------------------------------------------------------------------- <br /> F FACILITY NAME_5SC_PUgiaz- lt?D12.1LS `CO(2-Pn¢-h-�w1 YRs�-�________________ PHONE #U-CKI)_4-6 B"'31 d� , <br /> A +___________ ___ _ _____________________________________ __ __-______ ___� ________________________� <br /> C ; ADDRESS i s`o E, H R-z-f-c-o" ASV f- ` �le--TO1 CA <br /> I +------------------n------------------------------r---�T�----- -t--- -- c- -- J� <br /> L ; CROSS STREET V�,SG .L <br /> I +---------------------- --------------------------------------------------- <br /> _______________________________ <br /> T OWNER/OPERATOR T3 Am�'j M G C A*j KI PHONE # ' <br /> Y 5TC pu3+ KS-)Co2 Poo`—�LV_£T mAN G F-2 ------I -De <br /> ---+------- +- <br /> S-31O(o <br /> e'{b <br /> C 1 CONTRACTOR NAME $14 C-L--v 't�P-p RZS �.,/i PHONE # Fj Cq 367-46,..6------- <br /> ------------------------------------ ---------`— -_ T---- ' <br /> N ; CONTRACTOR ADDRESS 2370 p,G� C 1� �DT_1_CA-LIC # -7-_7__Trj ___g AZ 1 CLASS P­'F <br /> D_2, D <br /> T +___SURE________________ __TT_________ i ________.......................... WORK.COMP.# ry <br /> ----- --�--- ---- -- - �f A Q ,(� `1- <br /> R INSURER S 1�•C-�U'A�D�S TT .. E.C�'WS Q Z1ur- ..D v���-�•T <br /> C OTHER INFORMATION , <br /> O PHONE # <br /> PHONE # <br /> ---------------------------------------------------------------------------------------------- <br /> TANK ID # 1 TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 1 <br /> 39- L4STJL i 1S�000 6OLL- &6 (Z£.C,ucM�C I1�L�Ay£A <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> f; L APPROVEDAPPROVED WITH CONDITION(S) DISAPPROVED <br /> A TTACHMENT WITH CONDITIONS} <br /> N PLAN REVIEWERS NAME I" 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 OFC,ALIFO IA.- p �i <br /> I APPLICANT'S SIGNATURE: Nt TITLE ( DATE 10'3 M 0 <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 /> NameBA&LCY 6-YTF"¢.�- s� ,A.LAddress 23-7a twP,66,-ra cave x -ILL� Lcoz— Phone # 367`+&D <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />