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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. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> _TANK RETROFITPIPING REPAIRIRETROFIT_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +-------------------------------------�-------------------------------------------- -----------------------+ <br /> EPA SITE # , PROJECT CONTACT & TELEPHONE # W N C <br /> I +-------------------------------------------- -------------------------------------=------------------ - - ---- ---- ---- <br /> ' F FACILITY NAME N. PHONE #���_� ��C Z <br /> `y -ijjy�+ 1 tt11rr'' Z OS �? <br /> C ADDRESS y "tt7!✓�e - L�,.ICl_i_�'�! iLt_ <br /> II +------------ --__-- <br /> L ; CROSS STREET <br /> , <br /> , <br /> 1 T ; OWNER/OPERATOR PHONE # Qp <br /> Y l I ZCyS t. 0 6 <br /> '--- ------� --- ------ Z--y------------- <br /> ---------- -- - ---- -- -------------- ---- ---------------------- --+------------------- j, --, <br /> C : CONTRACTOR NAME (�-- ��,p-------------- <br /> _�_1 ; PHONE ­4Z3-7Z Z 4 <br /> O +----------------- tC� _'� fi�--- - -------r - - ----- ----------- ------------�-----i <br /> --------------- <br /> N : CONTRACTOR ADDRESS - 1 ,�v�n6 l� 2( CA LIC # � j O CLASS(Q} L�^� <br /> I T +--------------- - - ----- --------------------------------------------------------` <br /> --- - --- -- <br /> ' R INSURER Or � M,�J .e Z'-- - ----- -- ce- WORK,COMP.# <br /> ' A ---------'-'- �----------- -- <br /> ' C ; OTHER INFORMATION C ' <br /> I0 --- ------- -- - -- - ---- - - 1' f -------+-PHONE-#-------------------------------- <br /> R +-------------�L-cb--Cy12 iL�---S ,�cl�s - -------------------------- <br /> , <br /> PHONE # <br /> ---------------------------------------------------------------------------------------------- <br /> 1 TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED <br /> 39- <br /> T ; 39- _ <br /> A 39- <br /> N 39IVL-4 <br /> - <br /> K 39- <br /> 39- <br /> 39- <br /> P ; <br /> L ; APPROVED, APPROVED WITH CONDITIONS) DISAPPROVED <br /> A (SE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAMEDATE <br /> +--- <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 O CALIFORNIA." '^ -' L <br /> APPLICANT'S SIGNATURE: TITLE&1!6k.�/C� -AA-" IATE <br /> +---------------------------------------------------------------------------------------------------------------------------------+ <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 /> Name WC— Address Cdt,4VA( Gi GyC) Phone # <br /> Signature_'l '�i�c�.,,�� <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />