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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WESER AVE.3P 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 __jptpING REPAIRIRETROFIT UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT <br /> y — ---------- ------—---------------------------------------------------------------------------- <br /> ----------------------- -------------------- <br /> 1 QI <br /> PRW=CONTACT&TELEPHONS_#_ -------- <br /> EPA$ITS 0 <br /> ------------------------------- PHONE# <br /> F FACILITY RANH A k V. ------------------------------------------------------------------------------- <br /> A ---------------------------- <br /> C AVH=q ^A- 0 *r-,-A:- [>0'U - -- - <br /> --- - - ------------------------------ <br /> 'i LV <br /> I ----------- -- -------- <br /> L I CROSS STREET P(3 -------------------------------------------------------------------------•--- ---- <br /> I -------------- -------- PHONE# <br /> T OWNWOPERATOR <br /> Y -------- ------------- <br /> ------------ PHONE# <br /> C I CONTRACTOR RNNE S. --------- ---- <br /> II N y <br /> ----------------------- --------------- <br /> 0 ------------------ <br /> -7------- -.--'I S 9 3-V <br /> A I CA LIC# a, <br /> cmnvACYOR ADDRESS .0 tv,A ---------------1 -92... <br /> T----------------------- ---- ---- ------ <br /> *,%-e ------------ 01"ikAu------- <br /> IF ---------------- <br /> R INSURER <br /> 71 ------------------------ -- -------------------------------------- <br /> CT--O-n--=---n--n-w-Y-J-kT-T-O-"-------------------------------------- ------ ---- <br /> --- <br /> ----------------------I PHONE# <br /> 0 1 ------------------------------------------------------ ---------------------------------------- <br /> R ----------------------------- PHONE 0 <br /> --------------------------- <br /> ---------------------------------------------------------------- <br /> TANK IV w i TAM SIZE I CHEHICALS STORM CUREENTLY/PREVIOUSLY DATE UST'NE'n"M <br /> 39- <br /> T 39- <br /> A 1Ni39- <br /> 39-_-1 <br /> 39- <br /> 39- <br /> 11111 Hill ill Ill lill Ill ill <br /> P APPROVED APPROVED WITH OON91TIC0(S) -DISAPPROVED <br /> L A TH ITIONS) <br /> A DATE <br /> I lilt 11111 1111111 IIIIIIn 11111 nil <br /> N PLAN REVISHERS 4. ililllln 1114111&111111 <br /> IN ACCORDANCE KITH SAN jCAQuIN Cowry ORDINANCES, STATE LANS, AND RULES AND RSGULAT'Cus OF <br /> APPLICANT HUST PORPORN ALL"C" ONNUR OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINGI 'I CERTIFY THAT IS TIM <br /> PERSON IN SUCH A?U%XNSR AS TO <br /> SAN jOAq=CMb-ff, MMROW04TAL HEALTH D&PARTHENT <br /> PERForivAcE OF THE wCRK FOR WHICH THIS PERNIT IS ISSUED. I MAIL NOT ENPIM ANY CESTIFIRS THE <br /> ChLIFMZA." CON"rRACTOR'S HIRING,OR SUBCONTRACTING SIGNATURE <br /> EFS SUHjECr 70 WORKER'S 0014PERSATIC14 LAW OF CH THIS PERMIT IS ISSUED, I SHALL MGWY PERSC"S SURJECT To WORKER'S <br /> FOLLOWING, -1 CERTIFY THAT IN THE PERFOR14ANCE OF THE WORK FOR M <br /> COMPENSATION law OF CALIFORNIA.- <br /> TITLE <br /> APPLICANT'S SIGMTURZI <br /> ------------------------------------------------------------ <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 owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name Address Phone <br />