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SAN JOAQUIN COUNTY <br /> Sg- <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 RETROFIT _PIPING REPAIR/RETROFIT V UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +---------------------------------------------------------------------------------------------------------------------------------+ <br /> EPA SITE # -- �.C�//_/_f� '1 PROJECT CONTACT &-TELEPHONE #------Lr h��_�.���-/'fit/�^•..'1 u�"� "l���C <br /> ------------ -----A1C 1[LII::�Z'i SJ``` —a— -----�«— , -- SJSeLLJ (LZ' �}l � �l <br /> C FACILITY-NAME <br /> __F I�_`�_ _ _'J_V����-.!___�I(tCXC Lam_-_-___________-___.. PHONE #_ac C3--- -SZ4 __'e_-4-L--: <br /> F _1 �? _l <br /> A +--- --- <br /> I +_ADDRESS <br /> --- -----------------------� <br /> L CROSS STREETt n-fC} 1 <br /> I +-----------------� ---{----------------------------------------------------------------------------- - <br /> ---------------- <br /> T OWNER/OPERATOR__ PHONE # <br /> }- <br /> C ; CONTRACTOR NAME ",, '-� PHONE # 1..�" <br /> PL�L -� `~5 �1 � s 3E <br /> �_ tc _ C_ 3__ 45 <br /> N CONTRACTOR ADDRESS I ls' ---C- = CA LIC # �, _ Ll--__ CLASS /'u�lJ��� -; <br /> --- - -------------1-- -y� (fir— J^7 Y7 J q� <br /> R INSURER �uY`1C-- 14thl�t` SC¢h_"�" �A 'S/l.=- --'„"--L------------------+-WORK COMP_#------_4Z�� <br /> C OTHER INFORMATIONC `-1`�����,�� N <br /> X1.7 <br /> T +--------------------- --------------- ----------------------------------------' <br /> 0 PHONE # <br /> R +------------------------------------------------------------------------------------+----------gc�Q_--4-q,9 7-0%313----- <br /> ; PHONE # <br /> ------------------------------------------------------------------------------------ -------- <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> T 39- <br /> A <br /> 9-A 39- <br /> N 39- <br /> K 39- <br /> 39- 1 `?, sic- C <br /> 39- <br /> +---11 <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITION <br /> :_N_; PLAN REVIEWERS NAME DATE � n <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 /> � <br /> APPLICANT'S SIGNATURE: """` -.c'� - TITLE 6-177 <br /> DATE <br /> +-------------------------------------------------------------------------------------- ---------------------+ <br /> BILLING INFORMATION: 1)& w _ � WO^ * 6"4) <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 P- N C_NCO. Address 1,)g (Z1tj n d iil 81fid -lajWty✓Phone # 46423-ONK' <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />