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0 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3RO 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 _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />+---------------------------------------------------------------------------------------------------------------+ <br />EPA SITE # I PROJECT CONTACT 6 TELEPHONE # �KIVe- Eltr�jor____ yj qq3-g7ca __ 1 <br />1+______________________________________________________________________________________________ _ _ �`--_--__---_-_ -� <br />1 F I FACILITY NAME 114♦�` ..,J <br />Qa — AI._J_� ,y_ ,�_ I PHONE # <br />A --------------------------- -`- _- `— <br />-----------1--- --1�---- � w ------------( <br />II I +i ------- ----------I -r-- --1-- �'i` <br />--------------------- <br />C ADDRESSW.5- ------------------------------------- <br />----- <br />L I <br />I CROSS STREET I <br />----------------------------------------------------- <br />I T I OWNER/OPERATOR <br />i� PHONE # I <br />Y I VEk��e Q-6c,z 4v"111Scr�rc<� L�•� (°� It - <br />I- +------- -------�-----------------------------------� ---.-,-yr--------------+----------/�------------------------------I <br />1 C I CONTRACTOR NAME )o--- <br />IPHONE# <br />I,�p}�f ��____ µ r"'�l l��"______ ---C�� <br />I N I CONTRACTOR ADDRESS �Q (1 X �I �yTbµf C� I CA LIC # . i CLASS <br />�S b �/ Y1 <br />--------------------'-----I <br />R I INSURER f5 -7,e 1y 1 WORK.COMP.# <br />Ai---------------------------------------------------------------------------------+---------------------------------------i <br />C I OTHER INFORMATION <br />-------------------------------------------------------------------+--------------------------------------I <br />1 0 1 1 PHONE # <br />+________________________________________I <br />1 1 I PHONE # <br />+---------------------------------------------------------------------------------------------i <br />I TANK ID # I TANK SIZE 1 CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED I <br />t r439- 1 1Zj000 I �t-g�.t�c�v- )v. <br />T I 39- oo-e 1 <br />l A 1 39- <br />N 1 39- i I <br />I K i 39' i 1 <br />39' <br />1 i 39- <br />+---IIIIIIIIIIIIIIIIIIIIIIIII11111III111111111111111III LIIIIIIIIIIIIIIIII111IIIIIIIIIIIIIIII1111IIIIlIIIIIIIIIIIIIIIIIll111111111 <br />IPi .v// 1 <br />1 L I APPROVED __�AP�PROVID WITH CONDITION(S) DISAPPROVED <br />A I (SgiE wA T4 ITIONS) <br />I N 1 PLAN REVIEWERS NAME � � DATE <br />+ iiiiiiill111111l1, 77 -,ll i�idil,Ii ill Iililillliiiiliiiliiiliiillliililiiiliiiiiii11i1liH H11 M 111Hi "i m 1111 111HI M <br />I I <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF I <br />1 SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY I <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO I <br />I <br />BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I <br />FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO 1 <br />COMPENSATION LAWS OF CALIFORNIA." <br />I <br />1 i�GZ�O I <br />I APPLICANT'S SIGNAT �- TITLE ��Yl'"""��'� DATE <br />1 <br />I ' <br />+---------------------------------------------------------------------------------------------------------------------+ <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond <br />coverage per tank. If the party designated below is different than the permit applicant, e.g <br />the party must acknowledge this responsibility for the billing by signature and date below. <br />16` FeinL Lje4+ Gtvt-tom <br />Name 6 ex- Address S�-ck+o­ Cw- 4S2 -0(o Phone #_ <br />THAT IN THE <br />WORKER'S <br />permit payment <br />property owner, <br />(z.,q) 9IT-Igr2 <br />