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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3Ro FLOOR <br /> L <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 REPAIRIRETROFIT_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +---------------------------------------------------------------------------------------------------------------------------------+ <br /> EPA SITE # ; PROJECT CONTACT & TELEPHONE # <br /> F ; FACILITY NAME ` , PHONE # <br /> A +--------------- ---- ------- --! ---- ---------------------- ----------- - - ------------ <br /> C ; ADDRESS r' <br /> i <br /> L ; CROSS STREET <br /> T OWNER/OPERATOR PHONE # <br /> Y <br /> i_-_+__________________ _______________________ ___ ________________________-_-_--_--_______ <br /> C CONTRACTOR NAME -_ - .7 PHONE <br /> N CONTRACTOR ADDRESS <br /> T +-------------------------------- ---- ------------ -a ®p-- -�-CA LIC # �'4--- -----CLASS----- -- <br /> R INSURER WORK.COMP.# 1 <br /> AI---------------- ---- - ---- --------------------------------------------+------------------- ----- --- --- - <br /> C OTHER INFORMATION <br /> O 1 PHONE # <br /> PHONE # <br /> TANK ID # 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 /> 'IIIA.. II I II IIII IIlI „ , <br /> P <br /> L P OVEDtlAPPROVED WITH CONDITION(S) 7f- <br /> -1DISAPPROVED <br /> A \ (SEE ATTACHMENT WITH CONDITIONS) ®® Qe <br /> N PLAN REVIEWERS NAME DATE J <br /> APPLICANT MUST PERFORM L 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 /> w ® <br /> APPLICANT'S SIGNATURE: TITLE _ ` R DATE <br /> +------------------------------------------------------------------------------- -0025" - ----------------------- <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 a ddress v- o Phone#-n) G51 <br /> ® i ,CiA C16GDOl <br /> Signature <br /> �R o� <br /> E H230033 ® -ea ov <br /> (revised 1/31/02) <br /> V�Y--g s 4 LL <br />