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• • RECEPyL5L, <br /> SAN JOAQUIN COUNTY MAY 2 4 2004 <br /> ENVIRONMENTAL HEALTH DEPARTMEWVIR <br /> T <br /> 304 E WEBER AVE,JID FLOOR OWENT HEALTH <br /> STOCKTON,CA 95202 PERMIT <br /> SERVICE$ <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 /> ----------------------- <br /> -- - - --- - -•STANK RETROFIT _PIPING REPAIRlRETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> �� - - --------------------------------------------------------------------------------------+ <br /> i ; EPA SITE #I�� PROJECT CONTACT & TELEPHONE # <br /> +----------- -------------------------------- .......... <br /> I < <br /> F FACILITY NAMEPHONE # <br /> / \ , <br /> A+________________ C .k<- -` <br /> ___---------i------------------------------------ - I <br /> L ; CROSS STREET <br /> , <br /> T ; OWNER/OPERATOR <br /> I <br /> PHONE # <br /> Y ' okn Ktrn O--- --- ------------------------------- <br /> C <br /> ----------------------- <br /> _ <br /> / <br /> ----- --------------- -------------- <br /> C i CONTRACTOR NAME`ivY -- 1 PHONE # 7 <br /> N : CONTRACTOR ADDRESS f C � - ---------------J--- <br /> _-`_CA LIC # <br /> T +-------------------- f� D�--- '�'= -6------- -------—(�S 3 3��------�5-���1A�-L ') ; <br /> RINSURER G 1 /o ; WORK.COMP.# <br /> A ----`-----0 1J _tS S tYv` ---------------- U t to S-p- ----- <br /> C OTHER INFORMATION <br /> i <br /> T +----`---------------------------------------------`------------`---------------`----+------------------- ----`, <br /> 0 ! I PHONE # <br /> I PHONE # , <br /> __________________________________ _ <br /> TANK ID # i TANK cryoCALS.STORED CURRENTIIY/PR Y DATE UST INSTALLED <br /> 1 39- <br /> T 39- Q <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> �......iii <br /> ,,,,,i <br /> P <br /> L _APPROVED A APPROVED WITH CONDITION(S) DISAPPROVED 'c <br /> yQQ�1 �)TT('S��E� CONDITIONS) <br /> N DATE G V <br /> N PLAN REVIEWERS NAMEiI.,,,,,,,iii,.,.ii.i.i, <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 , THAT IN THE <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 /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO , WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: A41 Z. ^ TITLE y�{+p$ DATE <br /> ' I <br /> +-----------------------------------=�---�r-�-�;v-f�--�— ----�;,,-�;{•--� ---�- --mar <br /> BILLING INFORMATION: IA 4-4k 01-j. <br /> ,z-. SvAA.'u- A P� <br /> [�/-$ !Yo prw--, <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 /> NameA � lr �T Address 21 i(D A�' 6A Phone# ''A&- i'5 -10 <br /> 1 <br />