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0 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 3o4 E WEBER AVE,3ti°FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS PROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS_INDICATE PERMIT TYPE BELOW-- <br /> ---TANK RETROFIT PIPING RUAIRlRETROFI7 UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT <br /> +-------------------------------------------------------" --------------------------•---1 -- - -"--- --- -- <br /> I I EPA SITE # I PROJECT CONTACT & TELEPHONE # G - { -- - -------------- <br /> -------------- <br /> � -- - --+ <br /> I +----------------- --------------- +-Nf� <br /> --------------------------- <br /> F I PACYLITY NAME /) /'F1 PHONE a <br /> C I ADDRESS a - -- -- -- "-i <br /> --- <br /> I L 1 CROSS STREET ---------...-'-------------i <br /> II +---------------- -- ------------------------------------------------------------- -----------------------. <br /> T I OWNER/OPERATOR ----------------- <br /> I - i <br /> ( Y ! _ I PHONE # <br /> --- -------- ------------I - ---- y-? <br /> CWTRACZOR <br /> iI 0 I ---------- NAME /'`J /�,�/+ -�'{.��j/� ..�.�J�—, �J�''---HONE - I <br /> T {-OOWTRACTOR ADD&S3SJS.�i �.--.-.-"_•-I CA LIC-#_ !n!�!� „) �---�-CLASS£►L.JLr[_-- -- --1 <br /> -- <br /> 1 R I INSURER�. 1 I WORK.COMP.#�A I----------•--: - - -----• ----------------------------------------------------+------------ <br /> C I OTHER INFORMATION <br /> IT ---------------------------------------------------------------------------------------....... --- - -----. ------I <br /> l o l I PHorrE � / 52Yti.---- <br /> I R *------------------------------------------------------------------------------------*------- ? <br /> - i <br /> ' I PHONE # <br /> +---III1111III III III"It1111111111111------------------------------------------------------------- <br /> ------- --------------- <br /> ---------- <br /> I <br /> I I TANK ID # I TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED I <br /> � ! 39•_ I 1 I <br /> T 1 I 39- 1 <br /> A 39- <br /> i <br /> I ' <br /> 1 X 1 39- I I I <br /> I 139- <br /> 1 139- 1 I I I <br /> + --I 1111 1 Im iiml 1111111 l �!�1H HH �i 1 .1. 111111 I IIIIIIIII111111(11111111111111111111 7 ( Imi;111 <br /> APPROVED APPROVED WITH CONDITION[$) _AISAFFROs`ED i <br /> I PLAN REVIEWER, NAt� T ( EE ATTACHMENT WITH CONDITIONS) DATE <br /> �-•-illlll(II1111111111111111111111111111111111111111111111 II11 I .II; 11 �1,�,� 111111 1i II(111lllllilllllllll <br /> APPLICANT MUST PEAr*R E ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS. AND RULES AND ASGUL++TXONS OF I <br /> ISAN .JOAQUIR.CO(RNj'Y, ENYYRONME3ITAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT-S SIGNATURE CE2TIFIES THE FOV"INIS: -I CERTIFY I <br /> THAT IN TW -PERFORMANCE OF THE WORK FOR=WHICH THIS PERMIT IS ISSUED, I SHAAL �= -CWLOY AMY PERSOS IN SUCH=A MAINNER AS TO I <br /> I RECOMQ 811841= TO WORKER'S COMPF2 ION LAWS CALIFORNIA." AOR-8'HXtiZN6 OR SUBCONTRACTING SIGNATURE CERTIFIES THE I <br /> iFOLLOWING: -I CERTIFY THAT ZN P OP IEEE NORX FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBSECT TO i <br /> WORMS COMPENSATION LAWS OP RNI i <br /> APPLICANT'S SIGNATMr$ : TITLE <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 thebillingby signature and date below. <br /> Name Address v0 N* O "�4"honei%j0> <br /> Signatur <br /> 230038 <br /> (revised 1131102) <br /> 1 <br />