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-SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL, HEALTH DEPARTMENT <br /> 304 E WEBER AVE.3R4 FLOOR. <br /> $TOCKTON.CA 95202 <br /> APPUOATION 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 RZPAIRIRETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> *--------- _•^-- --------------- ------ -^ --------� ._---------------,------------------------- ---------_..-_-__---+ <br /> i •VPA sYTE"# I PROJECT CORTAcr S TELEPHONE # �[� �/•Qo I <br /> ' F + FA=-TTY.NAME `ehet 3 lw-i•-_-_ ------- <br /> -- <br /> ------_....-_G^,-(..---�_�_ _",_q_•---------'i PHON2 �F_`Q^'_! .���'cJlo l /�..------; <br /> C { AOApES6------- �...i I. r - _•e-..�.r��LL ---------------------- <br /> ----------------'__l='1 - ,_------_1 <br /> 1. L 1 CROSS STREET i <br /> x +---- --------------------- ------------------^----------------^---------------------------- - ------------- ------------- <br /> 1 T i OWUVR/OPERATOR i PHONE #vt <br /> ; <br /> i C + CaITPAC OR ivnrie S�,{,Oji .SiC� i�pyyU_ S f IS(�_F_._^--------------^--- i exciM # y-----�1. <br /> N + CONTRACTOR ADDRESS��'�\-/O.qG� _"`•"`-' _ �3.�L "_ `7°� �`"�.-'--CA Lir - Q��- -f'--------tY.Ab5�jcl 11 �,,rfA'Z eTIG <br /> ' T +____________________ v !/ ___.�_ _ ..__ i__ -- -.(r' -_ -i <br /> _ -- 1p��j �]�p <br /> i R 1 3; It k S `� i WORI;.COMP.# I lc7�T0 <br /> A i^-=--------- <br /> 9to�?___- _CYC ---- ----------------^-r-------------- (�_-�25 <br /> -•__. ---- ---r <br /> C 1 OTHER INFORMATIONI i <br /> iT -0---------------- ------ ------------.....-.y----------------------------- <br /> 0 I I PRONE P i <br /> i <br /> --------------------------------------------- ------------------- ......... -I <br /> i .. I PHONE $ <br /> r <br /> -------__-•^----------------------------------------....----____••------,---______-_—_,.-.-..-i <br /> I TANK ID # TANK SIZE CMMICALS STOFZ4 CVRA=TLY/PREVIDVELY DATE UST INSTALL= I <br /> ' T i 39- <br /> A 39- <br /> 139- J. <br /> i 39- <br /> I 39• <br /> i >ti I <br /> i L 1 DTi OVL•'D WITH CONDYTICH DISAPPROVED <br /> I A ; ssE ACI0IENT WITH CCNOITIONS) 'A <br /> I N PLAN REVIEWERS N$ME DATE U <br /> l 1171a r <br /> r..;.:•.r,r„ r,rriliiiirr, Ill ill i r, ..riil;ii.r 'i <br /> i , <br /> APPLICANT MUST,PERFORM ALL NCRr IN ACCORDANCE WITH tOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGVLATIONS OF - <br /> SAN TCAQVXN MWTY, VIRCN14MTAL I=TH DOWNER <br /> DEPARTMENT. OR.LED ICENSAGENT'S SIGNATVRE CERTIFIES THE FOLLOWING: •I CERTIFY <br /> M ; <br /> TRAT IN THE RERFORANEHC& OF THE WORK FOR WRICH THIS PERMYT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A$ TO I <br /> $ECOME SUBJECT TO wORxER 6 COMPENSATION LAWS OF CALIPORI4IA.” CONTRACTOR'S HIRING OR GUBCONTRACTYNG SIGNATURE CERTIFIES eS T99 <br /> FOLLONING: "I'CERTIFY THAT IN THE PERFORMANCE OF TSS WORK FOR WHICH THIS PERMIT is IS=21), I SHALL EMPLOY PERSONS SUBJECT TO i <br /> i WORIMRrS COMPENSATICN LAW&OF CALSFORNIA." <br /> I <br /> i <br /> j. InnT:Tmnmm nTntlnm(mnii T'f1TiFi i?Hi i <br /> BILLING INFORMATION: " <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> NameSE;rWCZIIS t3h" .ddress 0cSe) r 0i40 AVe,16 uk� Phone q6$-9,B'1003 <br /> SlgnatUre <br /> EH2soa3s <br /> (revised 1/31/02) <br /> G�� <br />