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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 REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +--------------------------------ANNA-- --- - --------ANNA-- ---- ----------ANNA-+ <br /> --- - <br /> EPA SITS # PROJECT CONTACT-- TELEPHONE_#_-_ ---- _ ANNA-_s _ --ex <br /> --i3o <br /> F FACILITY NAME PHONE # <br /> F� ------ — - ------------------------------------------- <br /> A +----------NAMEANNA----- �`�yJ9 y --I----------ANNA-----------ANNA-- <br /> C ADDRESS ® ®-- - - -®ANNA - -"-=-6T_ � �Fv'----- 1 y---- F�Z��A7ro`--�--- -=- �y7 ----ANNA-- <br /> I +--------ANNA-- ---s---- - <br /> L ; CROSS STREET <br /> I +----------------- --------------------------- <br /> ---- <br /> --------------------------- <br /> T OWNER/OPERATOR W M e- !;AWitI P ONE # <br /> y - t � --------4oT - lIi <br /> C CONTRACTOR NAME-410_644F ----`--���/_�-S ---� Z�------------------PHONE <br /> O +ANNA--ANNA-- <br /> ; <br /> N CONTRACTOR-ADDRES �� Am7 _ t-- -��----CA-LIC_#_ - ----� CLASS <br /> T +--ANNA---- Q L_ �'P ----------------------ANNA-- <br /> R INSURER O A)Bt o c �y'.y,1 _p g--- ���✓ �r. WORK.COMP.# Pi„ <br /> -- --ANNA--ANNA-- <br /> { T +-OTHER-INFORMATION--- 'V.-- l ,6J. F ®,moi ---1..5-&4�45,6S <br /> O - - _ _ PHONE # <br /> ' R +-------------------------------------------------------------- -------------+-----—-------------------------------- <br /> : PHONE # <br /> ---------------------------------------------------------------------------------------------- <br /> .....I TANKI IDI#II TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> +---;; II III .. .. ... .... <br /> P <br /> L ; APPROVED 11PPROVED WITH CONDITION(S) DISAPPROVED <br /> ' A A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME 1 (' �,� l� .�.% DATE <br /> + . .. .. .. . . .. .. i .... ........ ii..... <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 /> I <br /> APPLICANT'S SIGNATURE: TITLE 2 s (,4 3- <br /> +-------------------------------- -- ------------------------- <br /> ---------------------------------------—ANNA--ANNA-+ <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 /> Name Address Phone <br /> Signature <br /> EH230038 Se-,f C'en( L,'�,t:� <br /> (revised 1/31/02) <br /> 1 <br />