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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3RD 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. 00 NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYPE BELOW: <br />RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT <br />---------------------------------------------------------------------------- <br />----------------- <br />-------------- - <br />{ I <br />{{{ - r- <br />--- - ---- <br />------- { <br />-- --- <br />-- w- -�-----_! <br />-- -- <br />+EPA SITE # PROJECT CONTACT & TELEPHONE # <br />+------- - -455, <br />----- <br />F FACILITY NAME PHON# <br />---------------- <br />C ADDRESS ----- 4-----A *---------- <br />---- � <br />{ 2----------� - ----------- -------------- ----/' '-- _ - --- - --. { <br />{ L I CROSS STREET -� <br />{' <br />T { OWNER/OPERATOR ------ ---- " '{ <br />IYl <br />I ---+---------------r----------7 - - r �---------- ------ -- --- <br />NE : <br />{ C I CONTRACTOR NAME +---- --- ----- --- <br />{ O '----- ® --- ® I PHONE # ----- --�-'--------- <br />-- ---------------- --- 1 <br />N CONTRACTOR ADDRESS �° ------ -�--- - I CLASS ► - -- <br />-- <br />-- ----- _ <br />T +------- -- -------- CA LIC # P <br />- - - -- <br />R I INSURER Rie "^ - -- -- - -- -- /- --� -'` <br />A I------------- - - ------ - ------f -- I WORK.COMP.# <br />I OTHER INFORMATION ------------------------ _i <br />----- <br />C--- - -� ---- { <br />T+-------------------------------------- <br />_------- <br />R +_PHONE-# <br />i-------------- - --- I <br />___illlll{I{IITSIIIio{�{{Illlllll{{I PHONE # <br />--------- l <br />AN <br />T K SIZE i CHEMICALS STORED CURRENTLY/ PREVIOUSLY DATE UST INSTALLED <br />I T I 39- <br />A <br />9 A I 39- <br />I N I 39- <br />K <br />9 K l 39- <br />39-, <br />9 { { I I <br />394 <br />{ { <br />ifillilliIII Ii III I HlilM HI li <br />PI <br />L { APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br />{ A l (SEE ATTACHMENT WITH CONDITIONS) <br />{ N I PLAN REVIEWERS NAME DATE <br />*---I{III{II{II11111111111 l{Il II I I I II{ { 111 {l ill II { III11111 {I I !!I III !1!1111 It <br />i <br />i 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 l <br />l WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />I <br />i <br />I { <br />l APPLICANT'S SIGNATURE1 { <br />I TYTL _ DATE { <br />i <br />*----- ---- - ----------- ----- <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 />Name' AJAddress V hone #-314.1 <br />' 4- <br />Signatur J <br />EH230038 <br />(revised 1/31/02) <br />1 <br />