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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 <br /> �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 # _ _________ ___ _i_PROJECT CONTACT & TELEPHONE # pf�� 1\". �� <br /> +_________ h1 <br /> / q <br /> A I FACILITY NAME '1 IX ll�l 4A A- { ,0'�---------------------------------'_PHONE # <br /> ----------------------------------------- �'--- U -----------------------------------� <br /> C 1 ADDRESS __1� 3-�1 kr' P 3 fib__�C� T K " 1 4�off_C: <br /> I +____________ _____________________________ _________ ___y_____ _ __ ________________________________________i <br /> L CROSS STREET PO <br /> T OWNER/OPERATOR PHONE # <br /> Y W�__w �3 -`'4�i_ Bbl>C\�� --------------------�1 �� - �,'1�\ -V r� 1z�3 <br /> ---+------------- ------------------------ <br /> C <br /> -------------------- <br /> C 1 CONTRACTOR NAME A\ (� i PHONE # F�( •1 *�c Y �� <br /> O +_______________________________ _______________________________________________________________ <br /> ` � _int ------- <br /> N CONTRACTOR ADDRESS J,� "r-�w �- v�jA-y'`sLt-lr___CA-LIC-#- - -�l- -L,- ----- -C -rs--a y�-� rl--`..�•��LI <br /> R INSURER I WORK.COMP.# i <br /> -------- ---- <br /> I C i OTHER INFORMATION <br /> T +-------------------------------------------------------------------------------—+----------------------------------------i <br /> 0 1 1 PHONE # <br /> R +____________________________________________________________________________________+________________________________________I <br /> PHONE # <br /> ______________________________________________________________________________________________I <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> I K i 39- <br /> 39- <br /> 39- <br /> + iillii ili l�I iiHiii iii III Iiiiiiiii ����i�iiii�i�iii�i�iHill ill H Hill Hilli lliiii I <br /> P <br /> L APPROVED _APPROVED WEF <br /> ION(S) DISAPPROVED <br /> A i -{,5t R v 0 ATTAC ITIONS) <br /> I N i PLAN REVIEWERS NAME DATE <br /> +---illiiiiiiiiHill Illimill iiiiiiiiiiiiill 11111 Ill Ill I I ll Ill IIIIIIIIIIIIll IIIIIIIII111111iliIii 111li KI I I 1111"iI li ll IIIIII ii <br /> j <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 FOLIAWING: "I CERTIFY i THAT IN THE <br /> PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO I <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACT'OR'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 WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." ��yy <br /> r1 j <br /> APPLICANT'S SIGNATURE: TITLE eG e,t-!r— DATE <br /> i I <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 /> 1 <br />