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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTM <br /> I <br /> 304 E WEBER AVE,3R'FLOOR j <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERM7i <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDI;r'-_=E�--f7.TYPE-�=_`- <br /> _TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT P­=--jRf FIT <br /> +-------------------------------------------------------------------------------------------------- ----------------------- <br /> I I EPA SITE # I PROJECT CONTACT & TELEPHONE # <br /> I +-------------------------------------------- --------------------, <br /> F I FACILITY NAME -n22/ ��®/7 PHONE # <br /> I ADDRESS <br /> I / �- l' J71 - - <br /> ------------------------ <br /> LI CROSS STREET <br /> T I OWNER/OPERATOR I PHONE # <br /> -Y-+-�� ----------------------------------------------------------------------+- (,��51333.%�=----'--- <br /> C CONTRACTOR NAME s PHONE # —� <br /> J—/f0,«�IJ�Ot� sD.tJ-- ,-c c�T.iZ/L I -- - - - <br /> ---------- <br /> N I CONTRACTOR ADDRESS <br /> ? O��� CA LIC # 7 (lsJ3 /Gr Z <br /> { T --------------------------- ------- -_ l <br /> R I INSURER WORK.COK -- <br /> IA I---------- --------------------------l � , .N !!�'/`�/-------------------------------------------------------------- <br /> C ( OTHER INFORMATION I <br /> ---------'i <br /> 0 { I PHONE_#I ------------------- <br /> { I PHONE # <br /> +"'111111 VIII{III IIIIIIIIIIII1111----------------------------------------------------------------------------------------------� I <br /> 1111111111 I IIItII 1 111111111 - I <br /> TANK ID #_ I TANK SIZE I CHEMICALS STORED CURRENTLY/P'rr._=*�q { DATE _�- <br /> --'S --= <br /> I 1 39-�U� /Z�/1�� i � ©U ' i /�.�L 6-Af <br /> i T 1 39- <br /> I A I 39- <br /> i I <br /> I N 139- <br /> K I 39' <br /> 139-- I I I <br /> 39_ <br /> +'--11111111 111111 1111 111 111111 I11111111111 � � 111 � 11111 111111111 1111111111 1111111 11111 1111 1111111 , � 1ii <br /> Illlltl 111 ltl 111 lllllllll11111 � 111111111 � 111111IIIII11ED111111111IIIIIIII Itl11111III II III11111. ':.IIIIIIItII <br /> I / <br /> PI <br /> L I APPROVED %/11yAPPR WITH CO ITION(S) DISAPPRO7= <br /> A (SEE A A WIT ONS) ` ' <br /> N I PLAN REVIEWERS NAMEDATE <br /> +���IIIII11111IIIIII I11II111111111I III II{11111111111111`111 111111 1 ' 1111 I' III I 11111111IIII1111 i:�1i1111111i I111i1i1 .' ill <br /> I <br /> APPLICAST MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN IN COUNTY ' ES, STATE LAWS, F_7 R";LES AND REG7j--ATI0NS C ' <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIF'ES .ra FOLLOWING <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERS": LN SUCH A 11A.NNER AS <br /> I BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFO.4.NAVCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL L PLOY PERSONS SL3JEC TC <br /> WORKEER'S COMPENSATION LAWS OF CALIFORNIA." l <br /> I <br /> 1 1 <br /> I 1 <br /> 1 I <br /> I APPLICANT'S SIGNATUTRE: TITLE �%J(J-t'"^ � � DATE � 1 <br /> 1 1 <br /> ' -------+ <br /> -14 <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 /> Address,�, ,f-?3 Phone <br /> Signature -;F, <br /> EH230038 <br /> (revised 1/31/02) <br />