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R <br />e ' f'( 6 <br />ENVIRONMENTAL HEALTH <br />304 E WEBER AVE, 3RO FLOOR <br />STOCKTON, CA 95202 <br />r <br />DEPARTMENT �00� <br />(( 77 o41I t�I <br />T�1 <br />t �.rr3/ <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT ' `" `" ` ' `' ' `-' 1-: 1 <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 # Gol� 0002 Lj b V-_- I _PROJECT _CONTACT _&_TELEPHONE # �k� .Sa �� <br />+--------- --vi <br />�LG�"10 ' <br />----- - - Q--�-I-�------- 1�---- <br />I F 1 FACILITY NAME Lp"q j--CJi V---r�-r-^- i�-[- KI -,t -,,AA- �.f�l�`P -------- -------PHONE-#- -1 I� �7�1 V\J►� v---- <br />, <br />C ADDRESS 1. 8 C,- '�*A ' <br />------------------------------------ --------------------- — ---I <br />L : CROSS STREET N �,4�&. e ' <br />` •------------ — —---------------------------------------------------------------------------------I <br />T OWNER/OPERATOR ; PHONE # <br />Y <br />- <br />--+------------�--1-- -t- - --�c. <br />-------------- ------------- <br />--------1 <br />C CONTRACTOR NAME �v M--_------_-------------------------PHONE-#-G��� ��G� L��--I <br />O+----------------- ! ll <br />N CONTRACTOR ADDRESS�4�1-- ---------------CA-LIC - 00 -- t ------------CLASS--------------------------- <br />------CLASS----------- 1 <br />I R INSURER 1AUbSW,4 S(Pc-GP41 `,N �N <j�L�t'1\1�--Go`----------+-WORK_COMP_#__'�� jC7S,�------------I <br />' A ------------- <br />C ; OTHER INFORMATION <br />, <br />-- ----- t -----------------+------------------------------ <br />U ira(5 --- - -�- / O 1 �,-�----------------------- - PHONE # 1 <br />0 ' �( <br />--------------------------------- <br />PHONE # <br />+---;II ,,,,,1111111 IIIII111---------------------------------------------------------------------------------------- <br />II" " 'TANK ID # TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY 1 DATE UST INSTALLED <br />3 9- dopsas' &I C&'4) S'% 116 1 '1.0 0-0 b l WS <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39- <br />P <br />L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />1 AI ` SEE ATTACHMENT WITH CONDITIONS) <br />WN� 1 <br />N PLAN REVIEWERS NAME 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 IFORNIA." <br />APPLICANT'S SIGNATURE: TITLE ��� �wf "`��V /L DATE A)/—U fle <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 <br />Signature <br />EH230038 <br />(revised 1/31/02) <br />1 <br />Phone # <br />