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F <br />A <br />I <br />E SAN JOAQUIN COUNTY <br />NVIRONMENTAL 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 r -PIPING REPAIRgiETROFIi <br />_________________ <br />EPA SITE # <br />--__-_ _UNDER DISPENSER CONTAINMENT REPAIRARETROFIT <br />_________________________ <br />PAII.Tn r.� .�.. _ <br />L CROSS STREET <br />I-------------------- <br />I <br />_______ _____ <br />T OWNER/OPERATO <br />Y <br />---------------- <br />C ' CONTRACTOR NAME <br />0 +---------------- <br />N CONTRACTOR ADDRESS <br />I T +________________ <br />I R INSURER <br />C OTHER INFORMATION <br />T +____ <br />0 <br />TANK ID;9;;����� <br />39 / <br />T 39- <br />A 39 <br />N 39- <br />K 39- <br />39- <br />39- <br />+---i;iii <br />L <br />A <br />N ; PLAN REVIEWERS NAME A? <br />PHONE <br />------ <br />; PROM <br />CA LIC <br />----- <br />---------------------------------- <br />-------------------------------- <br />� --7 -------- <br />: <br />------ <br />; CLASS <br />WORK. COMP.# <br />_______________________ <br />I PHONE a______________i <br />___________________ <br />; PHONE #____________� <br />____________ <br />SEMI LS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />APPROVED <br />Mtc <br />IA��'�'.0 <br />APPLICANT <br />JOAOUIN COUNTY.ENVIRONMENTALPERFORM <br />IRONWORK <br />MENTALNHEAI,THACCORDANCE WITH SAN <br />MENTN WITH <br />COUNTY ORDINANCES <br />, STATE DISAPPROVEDLAWS, �;':';;':' <br />CONDITION(S) fff <br />H WITH CONDITIONS) <br />DEPARTMENT. OWNEROR LICENSED AGENT S SIGNATURE CERTIFIES RTHE SFOLLOWING: AND REGULATIONS <br />FY <br />THAT IN THE PERFORMANCE OF THE WORK POR 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 1N THE PERFORMANCE OF THE WORK FOR WHICH <br />WORKER'S COIPE6ATION LAWS OF IA . THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />+ APPLICANT'S SIGNATURE: n TITLE �� DATE <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 />— r, me party must acknowledge this responsibility for the billing by signature and date below. <br />666 Phone # , 537-9396 <br />EH230038 <br />(revised 1/31/02) <br />