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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL NENTAL 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 RETROFIT_PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> -------------------------------------------------+ <br /> ; EPA SITE # ; PROJECT CONTACT & TELEPHONE # ' <br /> +----------------------------------------------------------- --------1 <br /> ' 'F ; FACILITY NAME /(, PHONE # c S �9- /(..� <br /> f --------------------------------- ---------------- <br /> ; A +--------------------f------ - - -- <br /> , C � ADDRESS Q r��------------------'----------- , <br /> /5 - ---- �c-�G_7v:Y�n_ (Lc'�.e9. _ r ---C= ---_`_f' 3(��---------------------------------i <br /> L ; CROSS STREET ' <br /> I +-----------------------------------------------------------------------------------------------------------------------------I <br /> T ; OWNER/OPERATOR ; PHONE # <br /> Y <br /> ----------- ------------------------------- ---i <br /> C ; CONTRACTOR NAME ; PHONE # <br /> ---------------------------t v_Ls_ --------------------------------------------------------------------------------------- <br /> N ; <br /> +_CONTRACTOR-ADDRESS__6(�� C _ __.f..%.L/Lg[(.Qr -�-w �"-------------------- <br /> & - _ CA LIC # 6/ J(pU CLASS <br /> -----------1-1-------------------`-�---------------------- <br /> ; R ; INSURER ; WORK.COMP.# 3%L0 5S-_? <br /> ' .A '------------------------------------------------------------------------------•-------------------------- ----------� <br /> C ; OTHER INFORMATION <br /> T +-----------------------------------------------------------------------------------'+----------------------------------------1 <br /> 0 : ; PHONE # <br /> ' --------^-----------------------------------------------+_---------------------- -i <br /> PHONE # <br /> --------------- <br /> ------------------------------------------------------------------------------- S <br /> TANK ID #� '; TANK SIZE ; CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED <br /> 39- <br /> T ; 39- <br /> A ; 39- <br /> N ; 39- <br /> K ; 39- <br /> 39- <br /> 39- <br /> ......... ............i�ii���ri�r����� ir <br /> P <br /> L APPROVED 'APPROVED WITH CONDITIONS) DISAPPROVED <br /> A ; (SEE ATTACHMENT WITH CONDITIONS) <br /> N ; PLAN REVIEWERS NAME DATE l- <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 0 •ORNIA." <br /> APPLICANT'S SIGNATURE: TITLE O '" U DATE <br /> r <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 Address Phone # <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />