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• <br />SAN JOAQUIN COUNTY <br />• <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 REPAIRIRETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />+___i EPA SITE_#__-___ _______-__ <br />PROJECT CONTACT & TELEPHONE # <br />+ - - - - - - -- - ---- -- --- ---- - - - - ---- -- - - - - _ --- ----- ---I <br />---------- <br />F I FACILITYNAME E� - ----- J—%J- ----------- <br />-� ------------/'�,� <br />I C I ADDRESS $ e) k- i AA ..A P, . n� 0 Q <br />I +---------------- CTC�i Wqq g---,fy Fes+ ----------------------------I <br />--- <br />—_------ -- ----- ------ --------------------- <br />L I CROSS STREET11­141- <br />Z +______________ I- - �____� Y_"_ i <br />---------------------------------------------------------------------- i <br />I T I OWNER/OPERATOR PHONE # <br />Y 1 �✓ Fz ( ,S'; (� I c (v Icj - . p / G , <br />--+------------------ - ----------- --- -- - ----- -- - ---- - -- ------ - - - ' <br />C CONTRACTOR NAME `p <br />0 +------------------- - / 1 1✓L C\--h-�i <br />------ -"----------------------------PHONE---------------------- -----I <br />N I CONTRACTOR ADDRESS LJ y `____✓v� �� i CA LIC # +55 Fq" I CLASS i <br />T+_______________________ _ ___________ _ y�9�_ ___ k_ <br />I <br />RA i INSURER <br />__',�`�_�__��____________ I WORK. COMP.# � �/'�i �__1„�✓ � <br />I C I OTHER INFORMATION I I <br />' T ------------------------- <br />------------------------------------ 'j <br />0 1 1 PHONE #.J V <br />3 c <br />I i I PHONE # I <br />---------------------------------------------------------------------------------i <br />I i TANK ID # I TANK SIZE 1 CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED <br />39- i I <br />I T 139- <br />A I 39- <br />N i 39- <br />K i 39- <br />39-_ <br />9-39- i i i I <br />39- <br />+-- I;IiliiiiHi iiiIiiIiIili <br />P <br />ZAPPROVED <br />L APPROVED WITH CONDITIONS) DISAPPROVED <br />A <br />N I PLAN REVIEWERS NAME `tea t_"� <br />+--- ' IIIIIIIIIIII III IIII III;IIII;II IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIII IIIIIII III IIIIII 1 " II;I ILII IIIIIIII <br />I <br />APPLICANT MUSS PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS°`'0� I <br />I SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING. "I CERTIFY 1 I THAT IN THE <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO I <br />BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I <br />FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I I WORK$R'S <br />COMPENSATION LAWS OF CALIFORNIA." I <br />I <br />i <br />I APPLICANT'S SIGNATURE: TITLE <br />LLI NG C-91 4� ­­­'­� S(G <br />- 1*k <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 owner, <br />the party <br />must acknowledge this responsibility for the billing by signature and date below. //� <br />Name r 0-us� 64/k, ,1Address 30-3; W Q 4.6 LoOgk Phone # � 06 -73I <br />'152&i <br />