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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 /> 1 <br /> ----- ----------------------- <br /> ' ; EPA SITE # � � , PROJECT CONTACT &-T-E-L-E-P-H-O-N-E--#--a� � - - - --- ----- S --�--.s.----------------- <br /> -------+ <br /> F ; FACILITY NAME '� ---- -- <br /> ' PHONE # <br /> I A +---------------- --- <br /> e` -- _ `-----�P'--7-r---------------------'----------` - - - -- --- <br /> C ; ADDRESS ,�"1_ -- _��5�. M iTT _ , <br /> _L `rL C1 L_]�i <br /> L ; CROSS STREET <br /> II +---------------------------------------------------------------------------------------------------------------------------- <br /> T ; OWNER/OPERATOR , PHONE # I <br /> -Y - -- ------------------------------+------- --- <br /> -+-CONT-ACTOR- AM E i - - -- - -- <br /> C ; CONTRACTOR NAME �' ' HONE # ' <br /> o +------------------ ---- --- --- ----r - ----------- -i ----------- -- <br /> N ; CONTRACTOR ADDRESS6$G& ; CA LIC # 5 CLASS <br /> R INSURER , WORK.COMP.# 1 vt <br /> _ZV��•C� -- <br /> ` <br /> S ago <br /> C ; OTHER INFORMATION <br /> ' --- ----------- <br /> -------------------- <br /> 0 <br /> --------- - --- --O i PHONE # "�'� L..l�j` (� <br /> ---' <br /> PHONE_# <br /> TANK1 IDS# TANK SJZE CHEMICALS�STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED <br /> 39- `� . 1 <br /> T ; 39- <br /> A ; 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L ; �APP OVBD KAPPROVED WITH CONDITION(S) DISAPPROVED <br /> A ATTACHMENT WITH CONDITIONS) /)_�i\N PLANREVIEWERS NAMEi"'I' 06: CV= <br /> /= i 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 WS OF CALIFORNIA." <br /> APPLICANT'S SIGNA DATE <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 Address L3 . e 10k Phone j2'1V <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />