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0 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3" 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 # ; PROJECT CONTACT & TELEPHONE # M i c a ta,F'L <br />A +------------------4 c----------W/AO L �6o sr'(emg- lO6 <br />+-------------------- ------------------------- <br />___ ____ <br />F FACILITY NAME *5-7PHONE# <br />---------------------------------_-- <br />_-- <br />C ADDRESS IA -Z( S. C C A !S'- qO <br />L ; CROSS STREET <br />------------------------------------ ------------------------- --------- <br />T OWNER/OPERATOR�,1 v ((C S "'i✓Q YK K,c. iL 4,1-1;, � ,r PHONE # S (, 6 S-4 - <br />Y v� <br />{ C 1 CONTRACTOR NAME (l1/� 1 PHONE # -'54 - <br />�/V [. t"i�0 --- _ Ci''L E 2c Kest--- r . g----- — -------------------- <br />o+------------------- -- ----- 'r <br />N CONTRACTOR ADDRESSP._ --_-_ CA LIC # (� �, 3 = CLASS <br />R INSURER ; WORK. COMP . # 4 (3 O Q - of Z �O V- <br />ST arra------------------------------------------------ <br />C OTHER INFORMATION <br />------------'---------------------------- ----- PHONE # <br />,T +----------- 1 <br />O <br />----------- <br />PHONE # <br />+---11111;;;1111;11;11 <br />----------------------------------------------------------- <br />-- - <br />----------------------------------CHEMICALS ------------------- <br />TANK ID1#I TANK SIZE STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- O / 4D00 O A S <br />T 39- 000 N )T9 <br />A 39- t' 000 It 1 <br />N 39- <br />K 39- <br />39- <br />39- „ „ <br />P DATE <br />L AP VED APPROVED WITH CONDITION(S) DISAPPROVED01 <br />A r,/A -- l ( ��cc��TACHMENT WITH CONDITIONS) �I�Q <br />N PLAN REVIEWERS <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 />THAT IN THE 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 <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />J y� / <br />1 APPLICANT'S SIGNATURE: Li� <br />TITLECO ►DTZ A�C�►"� n� DATE $ Z O 6 <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 the billing by signature and date below. <br />Wp,LT-04 6$CGrAFN-1— P. p, BOY, rozr' 4c4 <br />Name Address 0, C a 9S-6 21 Phone # 3V5 - /( 5-2.- <br />EH230038 <br />(revised 1/31/02) <br />1 <br />