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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />3041- WEBER AVE, 3R0 FLOOR <br />STOCKTON, CA 95202 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT. OR PIPING REPAIR PERMIT <br />THIS PERMIT EXP/ES 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 />+-------------- <br />EPA SITE; # --- l PROJECT CONTACT 6 TELEPHONE II C�j (�v+ !� �6 �" '� C� 3 • D ; <br />I --'-------- -- ------ -------- ------ -----� PHONE <br />6 1 FACILITY NAME CQ�/��p1/'I7%OL_--!_Ld Z� <br />A,.----------------------- a RaP. <br />0 l ADDRESS ;Z;2;2 T. J'natn 1L�i _____-------------- <br />-------------------------- ------ <br />L ( CROSS STREET ------------------------------ <br />-- ---------------------------------------- <br />l T 1 OWNER/OPERATOR e ---J, PHONE Ii�0cr_ Ye -,Z - <br />e J 7��f / <br />/1�G,o c f a� /„ 1 <br />iY p___._ -.-__________________________________i <br />'-C-+-`-------------------- --------""--Q--__"_---_-__---_._./._��'_-------------------- � PHONE # 6�l^ ��.�" 'JLIO(S l <br />CONTRACTOR NAME tv'`jq I'h�/ Oh _ /- i`�-G f �/ OKl --- '-_'rf _- - ------ -_________--!_^__!__ <br />N +------------_--------n----- ---- -- -I �/ 1 CLASS C'" �� D ` o <br />0 /" &.e � 3 19' ��7/�• CA LIC i{ / �� �� 1 <br />CONTRACTOR ADDRESS ---- - - - � ��^ O <br />' T +----------- I7 <br />' ---- . ,L '----'-- WORK.COMP.I! Z�• VC% <br />C OTHER INFORMATION <br />f_____ -_____-.-______________.---__-___-____i <br />T+___________________________ <br />O PHONE # <br />PHONE <br />+-a--II- It <br />--- ----- <br />-- ---`------------ - --- <br />ID # D CURRENTLY/PREVIOUSLY <br />REVIOUSLY DATE UST INSTALLEDCCLS TORE <br />39- <br />6,11 <br />T 39- <br />A 1 39- <br />N i 39- ' <br />K 1 39- i <br />39- <br />39- ,,,, Ill, <br />P <br />1 L 1 APPROVED1 'APPROVED WITH CONDITION(SI OISAPPROVBD11 <br />nf ' SEE <br />A ATTACHMENT WITH CONDITIONS) 2 <br />I ,' I V DATE l� <br />N PLAN REVIEWERS NAME 1 N : (A <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." CONTRAC'TOR'S HIRING OR SUBCONTRACTING SIGNATURE CER'TI'FIES THE <br />FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUEJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." yy C <br />1 APPLICANT'S SIGNATURE: _ � 'TITLEI%tf�4Y�'iOn,T' �%9/_�-- llATE <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 moo. /Y --r 63ge o3 ,� Phone <br />1? 7 3 S -e <br />EH230038 <br />(revised 1/31/02) <br />