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SAN JOAQUIN COUNTY, <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />Sod 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. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />� m_40* t RETROFIT __PIPING REPAIRIRETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />•--------------------------------------------------------------------------------------------------------- <br />i I EPA SITE 9 { PROJECT CONTACT S TELEPHONE II (,,,.0 P i P,E�S j -j d Ll R ri' <br />f____________________________•__________y_�________-____-________-____-_-____•--_--__-_____-_____/_•_-_--_____________._tO_,__/,____ <br />{ F I FACILITY NAME - <br />0_0 Lk !`( I--- r4 -P- k 10 (N G t3 P_ P, G b 1 PHONE x <br />: <br />A r- ----- ---' <br />i <br />C I ADDRESS <br />I ?-----------�1�4 --5 ---------------------------------------- <br />' <br />------------------ <br />{ L I CROSS STREET ; <br />: <br />T { OWNER/OPERATOR <br />PHONE Y <br />5A is 3b A- Q U V N CO U tit -rt/ 1 Z 6� `f �� �- 3Z y p j <br />: <br />YI <br />{ I CONTRACTOR NAME -.p- c G ------------------ <br />C 0♦-------------- 1 r� ✓� -- S Y-S��L S I PHONE -� �iD O�- 10 -- � i <br />1 N I CONTRACTOR ADDRESS <br />I�CA LIC 45V'd!_QCLAS�S-QCQ�Q C� �t A��CR1 __--.__-----_________.-__-____-___Y_-__-T*-------------------------------------_UG� --- <br />R INSURER b-K-K1L�SC T-_-%7- -------------------------------------------------- <br />C <br />WORKCOMP9 <br />- ------------------------ -WORK.COMP. <br />C <br />C <br />---{ <br />1 OTHER INFORMATION <br />I----------•--------- ------------- ------------------------------i <br />{ O I 1 PHONE A j <br />{ R*---------------=------------------------------------'_------•-•----------•----------*--------------------------------------- ' <br />--II111111{III{111{1{1{{1{{1111111-•-------------------------------------------------- PHONE ----------------------------------1 <br />I TANK ID I I TANK SIZE I CHEMICALS STORED CURRENTLY/ PREVIOUSLY { DATE UST INSTALLED <br />I T i 39- <br />: <br />A I 39- <br />i N I 39- <br />K <br />9 K I 39- <br />A : <br />{ 39; _I I <br />i { 39: _ I <br />� _1 1{{{{HIM IHIii lit{{{{illi{111 {ilii{{{{{{{{{�' :il{i{{III'll1{{{lI Mil H 11 11{IIIi1 1 111{1111{{iii{{I{I{{{{{{i{{.i{{.{ <br />PI <br />L I APPROVED APPROVED WITH CONDITI DISAPPROVED <br />A I r (S T''ACHME.`JT WITH CON'lIiITZ ) { <br />N I PLAN REVIEWERS NAME DATE { <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: '2 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 HE { <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 CALIFOM41A.' <br />: <br />: <br />: <br />APPLICANT'S SIGNATURE: .�i T2TLE�_ `j/ DATE i <br />--------------------------------------._-___----_-_-_-__-___----.--_.---_-------___--_-__--_______-__�---______-__-____,_____---� <br />BILLING INFORMATION: <br />ndicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br />-overage per tank. If the party designated below is different than the permit applicant, e.g: property <br />)wner, the party must acknowledge this responsibility for the billing by signature and date below. <br />Vame_ L tL(=o _Address l� I _5 S"6N `,Tb9QL,1/�! Phone#2O� �� "3Z`iv <br />Signature Wk AA . <br />qr <br />H230038 <br />;revised 1/31/02) <br />