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SAN JOAQUIN COU TY' <br />ENVIRO (MENTAL HlEALTHE EPARTMENT <br />304 E WEBER AVE, 3RD FLOOR <br />STOCKTON, CA 95202 <br />APPLICATI N FOR UNDERGROUND TANK RETROFIT, OR F IPING REPAIR PERMIT <br />i <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />+----- --- -----------_TANK RETROFIT __P,IPING REPAIR/RETROFIT ___,_,UNDER DISPENER CONTAINMENT REPAIR/RETROFIT <br />r-------------------------------------------- ----- <br />EPA SITE # ) PROJECT CONTACT & TELEPHONE # r <br />F FACILITY NAME ,q/�lJ ---�-- 0�3 -- ---------HONE-----8'3s = !a b <br />PHONE # <br />C+-AD SOHO------ ---- - - ----------- ---- - ---- ----- -- - <br />I+ ADDRESS -- / !/C �F!�, G.- �[-r _'� \2i <br />L ,1 CROSS STREET - ------------------------------------------------ <br />I+--------------------------------------------------------- ------------------------------------ <br />�-- ------------------ ' <br />T ;-0WNER/OPERATOR PHONE # <br />+------------------ <br />0 <br />--' --- '--�'------------------------------------------------------ <br />C-- <br />CONTRACTOR NAME "� 1 PHONE # ; <br />o+-`---------- - --- I` <br />ICONTRACTOR ADDRESS tib �� ClG -- -7C/ ------------------------------------------------ <br />N/I T -----------.-------------- I CA LIC - -- � I -- -- CLASS <br />R ItTSURER / -1----------- <br />) --- a.--- -- -----•- --- <br />raie-__ Cr $ WORK.COMP.# <br />--- <br />OTHER INFORMATION - ------------------ <br />C ------ <br />T+-'----- ---- 1 <br />--q--�-�----- <br />R +---------------------------------- I PHONE # zoG1 _ 91 (6r-. l v C (o <br />---- -------------------------------------T------- <br />------- ------ -----------------------------I -- <br />LI ; PHONE # I' <br />TANK ID # TANK SIZE CHEMICALS SCORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />T 39- <br />A 39- <br />N 39- ' <br />I K 39- <br />39- <br />39- <br />+--- 11111111111111111 �, 111111 1'1111111111111111 111 1111111111111111111 �111111�1111 1111 <br />P 1111111111 I 111111111111 11111111111,1 <br />1.L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br />A ( SEE ATTACHMENT WITH CONDITIONS) <br />N-, PLAN REVIEWERS NAME IV DATE � <br />+ 11,1,11 111x111,1111111,111 'Oliiii 111iiii iii11111 1111111111111 .� � � '�� <br />111 1111111111111111111111111,1111111111111 <br />APPLICANT MUST PERFORM' ALL 'WORK IIN! <br />li ;, 1 11111�II�1 111111 111 1 11 1 1,11II <br />ACCORD CE WITH .:SAN 70AQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH EPARTMENT. OWNER OR LICENSED AGENT'S IS CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR W ICH THIS PERMIT IS ISSUED, I SHALL NCIT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br />BECOME SUBJECT TO WORKER'S COMPENSATION LkWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING: "I CERTIFY THAT IN THE PERFORMkNWdF 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: [ /A' C/5L4tL TITLE' 69, C2 n , DATE <br />1 <br />i <br />BILLING INFORMATION: �--� <br />I <br />Indicate the responsible party to be billed for additional EHD staf time expended beyond permit payment <br />coverage per tank. If the party d signated below is different fihan the permit applicant, e.g. property <br />owner, the party must acknowledge this responsibility for the billing by <br />1 signature and date below. <br />Name A dress L Phone # <br />L <br />Signature MM <br />EH230038 <br />(revised 1/3`1/02) <br />1 � <br />