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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 30 FLOOR <br />STOCKTON, CA 95202 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT. OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS F 7THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />_TANK RETROFIT _PIPING REPAIRIRETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />PROJECT CONTACT 6 TELEPHONE Y <br />EPA SITE i - ' <br />•- ---SITE----aI`"207T33 --SISI---- ----------------------------- '`= � --- h pr --------SISI---- <br />F FACILITY NAMEPHONE # 20q <br />T /may /�_•7�_______ ______________ <br />C ADDRESS %_�� (,�-_/ii'L!b________I0�________________________, <br />I�_____—________— ____�___ <br />L CROSS STREET --�--------- , <br />I♦----------SISI-- -l- -- ----------------------------------------------------- <br />T OWNER/OPERATO i f PHONE / , <br />Y' �� S� S r� n u t n r 2c6q- 9�k- /. S'97 <br />C CONTRACTOR NAME ' <br />O ------- ---- SISI-- __ tIU1E r SISI--- '�✓•(�/L------------ PHONE- �--- <br />N CONTRACTOR ADDRESS <br />T .SISI------} - -f-,0_ ---q ��_�1_ i � t�g�s 1 CA LIC a ----- J�5- �=_- (�-V------ <br />R INSURER .1JSc{.0`__C.i`�--------------------------SISISISI--- i WDRK.ODMP_ �1 Jib------- <br />, A ,_________ _ _ __ _ _ __ <br />C OTHER INFORMATION , <br />T--------- —_—__—--------------- —----- —---- --- —_—__—_—_—----- —----- r ______+_______________________________________ <br />O ; - ; PHONE N <br />R------ —--------------------- —--------------- --- ______---- _--------- —_________+________________________________________ <br />, PHONE { <br />_—------------ —_—__—_—___________________________________________________________________ <br />TANK ID 1 TANK SIZE CHEMICALS STOg//�_D /(/�7RR�f-NTLY/{PREVIOUSLY DATE UST INSTALLED <br />39-i�co231ii�iSOg"aK3 l; (�� 000 Isrt /PrArs' e t jl P / P20102 <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39- <br />P I <br />L APPROVED APPROVED WITH CDNDITION(S* DISAPPROVED <br />A �`.�(SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAMESJC%- :-C yA.,C�, 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 />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 COMPINSATICN LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE FORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />COMPENSATION LAW OF CALIFORNIA." , <br />C� <br />APPLICANT'S SIGNATURE: I:LS!�— �TITLE �YJL1iXZ moi' DATE 46-A''-/ ' <br />+---------------------------------------------------- ---- <br />----------------------- --------------SISI----------------------------i <br />BILLING INFORMATION: 3(1 OFIF A4�QzJh-� <br />THAT IN THE <br />WORKER'S <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 />Name rev, n (S' btu44c►- Address 6,171 )— cI i'%�v� Phone # 209'-9qg- /S'97 <br />1 <br />