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F FACILITY NAME <br />A eitieh,a,T c PHONE # - 5'4/- g 743 <br />C ADDRESS <br />CROSS STREET <br />45 ILi. • ir.,Lignaal-- <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3R0 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 _1,ZP'_ !PING REPAIR/RETROFIT __UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />EPA SITE # <br /> <br />PROJECT CONTACT & TELEPHONE 1066)51.. wift-Ti) .40R -5's6 - <br /> <br />T OWNER/OPERATOR 1 PHONE # <br /> ; 305 941- 8 743 <br />C CONTRACTOR NAME orwpa.. irveneur\c4. 0 <br /> <br />PHONE # -7t) - 5Sts-6- <br />CA LIC # 30.8141 C's <br /> <br />S1evr N CONTRACTOR ADDRESS 3aDei <br /> <br />R INSURER <br /> 5-Teri e- <br /> <br />D <br /> <br />WORK. CCNP # 085 <br /> <br />C OTHER INFORMATION <br />0 <br /> <br />I PHONE # <br /> <br />I PHONE* <br />TANK ID # i TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED <br /> <br />39 - 1 <br /> <br />T 39- 1 1 <br /> <br />A 39- 1 i <br />39- i 1 <br />39- 1 <br /> <br />39- 1 <br /> <br />39- 1 <br />--- iiiiiiiiiIIIIIIII:Willi 1H11" <br />P 1111111111111111111111111111111111111111111111IIIIII 7 <br />APPR APPROVED WITH CONDITION(S) <br />(SEE ATTACHMENT WITH CONDITIONS) <br />DISAPPROVED <br />DATE t 103' <br />A <br />PLAN REVIEWERS NAME eaktA <br />1 11 11111 111111111 11 11111 HI 111111111 11 I III I I I II I II 1 I I I 1 II II I II 1 111 1 1111111 III III <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN cowry, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />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 />I FOLLOWING: °I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />COMPENSATION LAWS OF CALIFORNIA." <br />THAT IN THE <br />WORKER'S <br />APPLICANT'S SIGNATURE: f,)7 A>) <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 owner, <br />the party must acknowledge this responsibility for the billing by signature and date below. <br />5,AA71.4.'i-- 5 To -77.) 0--) 5 yc-T6i-is 7 "3 <br />Name Address 681) Ouln Phone # <br />Sag- Sbs <br />1