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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: n. <br /> _TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT x slaAwo t <br /> +------------------------------------------------------------------------------------------------ -------------------------------+ ` <br /> I EPA SITE # ; PROJECT CONTACT 6 TELEPHONE # ��+ U _ 3-�03 8 <br /> +------------------------------------------------------------------------------------F------------------------ --------- <br /> ^-� <br /> F I FACILITY NAME ��,e __-Vl________________________________ ; PHONE # `�19 t <br /> ; A +-FACILITY-------- ` --------------------H(O�N�E(-----Q---`--�-------��---------I <br /> C ; ADDRESS ----O`--W-� -�-- t.----------�------4-------------- �-------------------------------------------------- <br /> L <br /> '-------_(T 1----------------------------I <br /> I : ADDR--SOHO-- - - <br /> L I CROSS STREET l.-;" <br /> I +------------------------------------------------------------------------' <br /> T ; OWNER/OPERATOR i ; PHONE It I� <br /> Y ' cU`l <br /> '1_--- 5 --+--------------------------------------- <br /> V*Cb <br /> . .. ) C 'CONTRACTOR.'NAME= .�\CO C � _C _Cf�- �_j-'� `�_ _________________PHONE-#_ � g , .. . <br /> +-___ 4 _4 c� /psi S ` _ _ ----------------- <br /> 0 <br /> N CONTRACTOR ADDRESS �J O &Ult&[A-AEU-e...- Ste, JCFO _-CA_LIC-#_-yb'S'j r4 , CLASS. $,C6l e�Lto iY_ <br /> T +--------------------- --------- -- -�--------------- r <br /> R I INSURER �� IJ �U I WORK.COMP.# �,�,I © ,c'�63 Co7I ; <br /> ' A I----------- -- -_----C-�--��---�----------------------- +-- <br /> C OTHER INFORMATION <br /> ' ------------------------- --- --- ------------- <br /> ------- <br /> 0 ' ' PHONE # 46 F- 3.._(0,073 0 <br /> R +------------------------------------------------------------------------------------+-------------------------------- <br /> ------------ ------------------ ------ <br /> TANK ID # <br /> --- - <br /> TANKID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P ; <br /> ( L I APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A ; 1-1 ATTACHMENT WITH CONDITIONS) <br /> N ; PLAN REVIEWERS NAME 11kA& DATE <br /> APPLICANT MUST PERFORM ALL WORK IN CCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THATI. IN-THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO. . . <br /> BECOME!SUBJECT TO WOR1WR'$: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 /> APPLICANT'S SIGNATURE: 1W TITLE IAW�.LL a��l�^�IATE lQ, �V'�+�^' ; <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 /> °1 S�la- <br /> Name MP ZVtW V, lu&TI:44A&�ddress � O S -I cA Phone# 46P voAl3-6035 <br /> Signature Jur V <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />