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0 <br />SAN JOAQUIN COUNTY <br />0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3"0 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 />, l�1� L _ <br />F ; FACILITY NAME S.L L lv L 5 l 1 '�i 3 �%� - ~ �q!�� ��^^1 , �.� ;( i PHONE # a +� cQ <br />A ------------------ _____r----1 ��_________ Li`__ [' on_______-- --`�-3-____ _ ___----_; <br />C ; ADDRESS ��-rx'1�1__�LQ91 i�C _ <br />7 <br />' L ; CROSS STREET L <br />Si <br />; T i OWNER/OPERATOR , PHONE # <br />Y ; X4.5: DoE l�_ �N� 11e11 �'ndl�fpn �a� as <br />---+-------------------------------f --------------- = M--5-------- ----=---------+--------- ----- `----- _---------------- <br />i C ; CONTRACTOR NAME _ n L y� - ---- - -- ' PHONE-#_ 9_->L-__ _-- , <br />I 0 +------------------I—]-{�1_ft'--j.'lJ�iro,�m�nlal_C'��n tru fi�D =--- --- -C -Q�X -U�7�-------' <br />N i CONTRACTOR ADDRESS P/l_yZ �7_ 2/„,�- m�-' L'C---1.�0---------------CA LIC#'�tJS �'2 ------I CLASS_/1 �?_/© <br />T -------------------- _ .3SJJ 3311 rl`t______ d 1.Li _+d L�,}___C �___________, <br />' R ; INSURER 45x� r7 �,` f - <br />A --- �v_C� YYIi_ s_ _�- 1 02 ------------------------------ WORKC # <br />fixffL_ , <br />C ; OTHER INFORMATION <br />0 I ; PHONE # <br />; PHONE # <br />TANK D # 1 TANK SIZA ; CHEMICAL STORED CURRENTLY/PREVIOUSLY ; DATE�ST INSTALLED <br />39-�YL7.231R SDSZ�SIgSi /S R, 4a-llOnS ; adlea��ed- ;�, 4+'i <br />T 39- <br />A ; 39- <br />N 39- <br />K ; 39- <br />39- <br />39- <br />P <br />L ; APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br />A ; (SEE ATTACHMENT WITH CONDITIONS) <br />N ; PLAN REV IEWERSNAME 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 />( <br />\� - Free* mn4nag nte'�r <br />APPLICANT'S SIGNATURE: c� R`ITLE/'!`lY)�-C�r9L�Pd1�' DATE <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 Phone <br />Signature <br />EH230038 <br />(revised 1/31/02) <br />