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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 EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />_TANK RETROFIT _X_P4 G REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />+------------------------------------------------------------------------------------------------------------------+ <br />1 EPA SITE # ---; PROJECT CONTACT & TELEPHONE # <br />F FACILITY NAME p c <br />A +------------------�ri`t -- 4 C 1 Y� C ---� l� ---------------------------�ZJ�----- <br />,�}} (� -- -- ------ HONE # <br />1 C i ADDRESS l) Z 1 Q"(tsjM1� I'tVC S�pcVj�+y C14 <br />1 I+------------------------------------------------------------------------------------------------------------------------' <br />L 1 CROSS STREET <br />T 1 OWNER/OPERATOR 1 PHONE- ; <br />Y <br />1---+----------------�.� (�-- P i 2 ----Qe rd -- y't------ `�"�c-+-------- ------ ---- -- - i f- [ -- ------ <br />-------------- <br />C I CONTRACTOR NAME 1 °fG (V Gp N� Y 1 PHONE # <br />1 0 + <br />------------ ---------- <br />---------------------------------------------------------------- ------- ----) _ 4 l�I-hr 33�------; <br />1 N CONTRACTOR ADDRESS CA LIC # O CLASS O <br />{ ! f �i <br />i T+------------------------Z.1-�1___ 1_7� MTQ 1/1. 1�i JL �_-~6r_"yl---------�IV �%ii ---------i----i <br />--------------------- ------------------ <br />R <br />- <br />R 1 INSURER Irw WORK. COMP. # 1-7 (� Vf I $ <br />A1----------------------------------------------------------------------------------+----------------------------------------1 <br />C I OTHER INFORMATION <br />i <br />i 0 1 PHONE # <br />i <br />PHONE # <br />---------------------------------------------------------------------------------------------- <br />' TANK ID # 1 TANK SIZE 1 CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- i �a v Clv L'C£G <br />1 T 1 39- <br />1 A 1 39- <br />1 N 1 39- 1 <br />K 1 39- <br />39- <br />39- <br />+---11 <br />............... 111 11111111 111111111' . . 11:.:111111111 1111111111111 11'1 <br />iiia iii iiia i' <br />P <br />1 L 1 APPROVED 11APPROVED WITH CONDITIONS) `(�[ <br />DISAPPROVED <br />1 A 1 E ACHMENT WITH CONDITIONS) <br />1 N i PLAN REVIEWERS NAMEt$Ql.�\6 DATE <br />+--- 11 <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 />APPLICANT'S SIGNATURE: <br />+------------------------ ------------------------------- <br />BILLING INFORMATION: <br />TITLE ktk akCe✓"tvV"y DATE qu C' <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 V4(lei, 4, 92 klmk,,Address /G►%.:k k Weft C,y.c k % 7c,� Phone # C"-,) f qr-y i IL <br />Signature <br />EH230038 <br />(revised 1/31/02) <br />1 <br />