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0 0 <br />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 REPAIRIRETROFIT <br />+------------------------------------------------------------------------------- <br />-EPA SITE # -------------------------- <br />�H q� L A L .� i,( ( -+ <br />I PROJECT CONTACT & TELEPHONE # <br />------------------------------------------ -------------------- -------- -- <br />F ; FACILITY NAME-� -�--J1 r <br />-(�-A (IV( . PHONE # <br />A+----------------- -------------------------- ----- - 3 2 3 <br />---- n�(a <br />------------------------ <br />ADDRES <br />C------s / 3 0 1 _ E C T G Gh h h1 L Al - _ ------ <br />L ; CROSS STREET <br />N <br />, <br />T OWNER/OPERATOR PHONE # <br />Y PeT C;(zAPF!artA <br />z® 33 -3 2-33 <br />-- <br />- <br />C ; CONTRACTOR NAME <br />0 +------------------- UJ A, L 1-01, --- 5,4C,- -4 S E•¢ (K il--- C PHONE # / e 6 - 3 4 3 _ u --------------- �� ----- ' <br />------- <br />---- ----------------------------------------- <br />N; CONTRACTOR ADDRESSQ x (0 Z r W, S A_ ,..._ C, Ap S 6,9 CA LIC # 6( :, 'L 3 r- ; CLASS A D N q Z <br />T-------------------------------------------------'-------L- ------------L-D-�-------------' <br />R INSURER ST A -r E Fo m <br />' A -------------------------------- -- WORK. COMP_#--- (3 OOO <br />C OTHER INFORMATION <br />, <br />O1 PHONE # <br />R+------------------------------------------------------------------------------------------------------- <br />PHONE # <br />---------------------------------------------------------------------------------------------- <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- O/ ZO, 00O AS 8� <br />T 39- � Z / O 00 0 , tit It I <br />A 39- G3 /O� 000 IV -SEL <br />N 39- <br />K 39- <br />39- <br />39- <br />+---' „ „ ...„ . „ llll 11 „ „ ....... <br />„ „ „ <br />L - APPROVED APPROVED WITHCONDITION(S)1111 ” 'DISAPPROVED111IIIIIIII" II'IIII'fll" ,1 <br />A (S E ATT ENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE dtAll`y-�•Ob <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 />M. <br />APPLICANT'S SIGNATURE: ��4TITLE CoTQA-C%r'QDATE ( O 6 <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 />WN .1-0"4 P.C. ROK lois q4 <br />Name E�stC,(aSS12;1a Address l�l� Seo, CA 9r6g, Phone# 3}3 -wrz- <br />Signature <br />EH230038 <br />(revised 1/31/02) <br />1 <br />