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DR, <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT /'hR 3 0 2002 <br />304 E WEBER AVE, 3PD FLOOR <br />STOCKTON, CA 95202 f I I <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 PIPING REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />+------------------------------------------- <br />EPA SITE # CSLO �fZ sZ PROJECT CONTACT &TELEPHONE #�� eL e 1� I - 36 8 -6W31 <br />+_____________________________________________________________________________________________________________________________I <br />F FACILITY NAME �G <br />PHONE <br />#2z0? -36o9 <br />C ADDRESS f <br />(� ��UfiL <br />--0t0--5 <br />--- <br />AA <br />1 L I CROSS STREET ��loelm s� <br />1 I+---------------------------------------------------------------------- <br />--I <br />T I OWNER/OPERATOR <br />PHONE # <br />I Y I (960 64 K / Df� <br />1 24q - s68 -066 3 <br />C I CONTRACTOR NAME <br />I PHONE # <br />iO + <br />------I <br />N CONTRACTOR ADDRESS <br />I CA LIC # i CLASS <br />R INSURER <br />I WORK.COMP.# <br />A--_______+_______-_ <br />C OTHER INFORMATION <br />T+___________________________________________ <br />--_____________-+---_____________-_----_ _- <br />I O I <br />i PHONE # <br />1 R + <br />---________+___----- <br />I PHONE # <br />------ <br />-' -----------------1 <br />TANK ID # TANK SIZE <br />39 7-9 S 7-76Z 1Z, GbU <br />1 CHEMICALS STOREDY/PREVIOUSLY DATE TjjT NSTALLED <br />I /�i09OC !�E•"-7�N� %YlE� 1 %`!� <br />T i 39-Ti7 <br />AI 39- <br />N 39- <br />K l 39- <br />39- <br />39- <br />+___IIIliiiiillllilllllllllllllllllilillllliillllllllllllllllllllililllllllllllllllllliillillllllllllllllllliiiiiiiilllllllllllllll <br />PI <br />L ( APP X APPROVED WITH <br />CONDITION(S) DISAPPROVED <br />A ( 1T <br />WITH CNDITIONS) /O <br />N PLAN REVIEWERS NAME �'� <br />+---illiiiiililllllllilllllllllliiiiilillllllllllllllilliiiiillllllllllllliiliillllllllilllllllllllllllllillllllllllllllllllliliiil <br />DATE (p <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />1 SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR <br />LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br />NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO I <br />BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR <br />WHICH THIS PERMIT IS ISSUED, I SHALT. EMPLOY PERSONS SUBJECT TO <br />COMPENSATION LAWS OF CALIFORNIA." <br />I <br />1 APPLICANT'S SIGNATURE: L9L <br />1 <br />/` //{.jam///J S �p <br />TITLE ----iY -�"� DATE <br />+-- - -- -f-------------r-----"-�--c ------- - 1 ------------------ + <br />a � IJ��(cR e� (Asp /c-- T�+- ov��l2 er A ee��S S t�G�^n(C%" u5 <br />4u- At\f\* L VVDJ-\LS <br />Prop& . <br />BILLING INFORMATION: <br />THAT IN THE <br />WORKER'S <br />Aga% (4 bvL <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 />,1Jrft — -- '� 11t --- Phone #------- <br />Nam C%D <br />___AddresslJ�S' _ <br />Gos�z Cf vJ'y94d <br />