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Jul 07 06 09: 43a Jeffrey C. Henley 714-i9- 1499 p. 4 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3"D FLOOR <br /> STOCKTON,CA 96202 <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 /> --------------------------------- <br /> ---------------- + <br /> , EPA SITE # I PROJECT CONTACT & TELEPHONE # <br /> i +------------------------------------ <br /> -------------------------------------- <br /> F ; FACILITY NAME t _ Z�I=i <br /> ' PHONE # t --- - {-- . ` G• ^� <br /> --------------------------- <br /> ; ____ __ ___________ <br /> C i ADDRESS _ <br /> ----------------- `-- "2---- <br /> i L ; CROSS STREET <br /> T OWNER/OPERATOR PHONE # <br /> -- YLL� r <br /> Y ' tE� -------------------- <br /> C i CONTRACTOR NNS T r,/\ --- ` _ -- PHONE # <br /> 1 O +----------------------- `"^ /_ -+Ch4--�.d ;�_� ,Ao ------------ <br /> ASS <br /> T ; CONTRACTOR ADflREss---- '`�---- �--cs_�1_'�z�16�i..-_�=------LIC-k �C1_Z_a�5---------- <br /> N 10C <br /> +- --- <br /> R INSURER <br /> I WORK.COMP.# <br /> IA --------------- ----1�1cT� _ _I"_"�_1t�_ _ �!f�1�Za---------- +-------------- ---------------------- <br /> C <br /> - ti - t�S--_ ZOO;'7 <br /> C OTHER INFORMATION _ -- - - - _ -- <br /> , <br /> O PHONE # <br /> . R _____________________________________________________________________________________________________________________________, <br /> ____________________________________________________________________________ ___ <br /> PHONE # <br /> TANK ID # TANK SIZE i CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED <br /> T 39- <br /> A 39- <br /> N 39- <br /> K i 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVEDI APPROVED I WITHI CONDITION(S1111„ DISAPPROVEDi 1 , <br /> A � , (� (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME .��) DATE <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 WORKHR'S COMPENSATION LAWS OF CALIFORNIA.' COIPPRACTOR'S HIRING OR SUBCONTRACTING SIGRATURE CERTIFIES THE <br /> FOLLDNING: "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: TITLE V"f" DATE T Q-6 <br /> +------------------------------------- --------- <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 /> Name-c�i� L.np&.S—c Address �Phone# I- .,r- �7 <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> z <br />