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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 REPAIR/RETROFIT <br />+-------------------------------------------------------------------------------------------------- <br />EPA SITE -# I PROJECT CONTACT & TELEPHONE-#---� <br />+-------- --- - - ------------p----------------------------------- <br />F ; FACILITY NAME -- Q tit (L S 7-- Q 1 � / Z t I -PHONE -# <br />A ---------------------------------------------__ <br />--------------- - ------------------------- <br />C ; ADDRESS S- O �- A 5 r- <br />---------------------------------------- fes- ---- —��---+----� '4-------9.3 k-------- <br />L ; CROSS STREET <br />, <br />T OWNER/OPERATOR PHONE # <br />Y _GvII& S-ra✓� PrR� sto - 6 r� �s o <br />(M �t`� ��-t - o <br />C ; CONTRACTOR NAME---- PHONE# 6 <br />0 +---------------- ---r0 E --------------------- _=< 3_} 3_ -I ' <br />t r -- ----- <br />N ; CONTRACTOR ADDRESS 1 / <br />T ------------ ------------��-- -- 0 lI _ I O Z i'�--- = S ----CA-LIC # L, i Z. 3 CLASS /�` a <br />----------------------------- �- _J_-_______, <br />R INSURER � T ��I 1P7 N--t>WORK.COMP.# <br />A'-------------------------------- +- <br />C OTHER INFORMATION <br />0 , PHONE # <br />, <br />PHONE # <br />+---111111 IIIIII III111,,,,,,,,, ---------------------------------------------------------------------------------------------- <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 />P��- <br />L 2.RC <br />A <br />N PLAN REVIEWERS NAME <br />:D APPROVED WITH CONDITIONS) DISAPPROVED QI�S <br />"ATTACHMENT WITH CONDITIONS) <br />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 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 />014 <br />APPLICANT'S SIGNATURE: TITLE CO -k-7 (C A"�/�TY!'H DATE 2 O G <br />( WfYC F A c TTOK <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 />WPI ctc-( p, m , 6 X /o z r <br />Name s`.g,:2 cµc Address W . s A4—ty c A 93"& -, i Phone # V6 -3 --3 -to- L <br />Signature <br />EH230038 <br />(revised 1/31/02) <br />1 <br />