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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3Rd FLOOR <br /> STOCKTON,CA 95202 DEC 11 n 4 2002 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT R, 7 <br /> THIS PERMrT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT'T.YP'>�BEL�a�!{{NV <br /> r���(���� <br /> i- ,6701/,> NVICES <br /> ____TANK RETROFIT __PIPING REPAIR/RETROFIT ___UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +------------------------------------------------------------------- <br /> 1 EPA SITE # l PROJECT CONTACT & TELEPHONE # I <br /> - -Vii- -------------`—----------------------------------- <br /> P I FACILITY NAME s A 45�I /77�/&, __i-PHONE #- _____.-���__ ______i <br /> ________ <br /> _________ ___ <br /> C 1 ADDRESS -- / ° <br /> I . 1-- �D1> �/_ <br /> l <br /> I L 1 CROSS STREET <br /> Y-_OWNER/OPERATO .-�_�_______ ___ ______ _ _ __________________i_PHO _#___✓_ _ _J_ _ _r__� <br /> C CONTRACTOR NAME_-- 1 I / / ]� / //� ///��� PHONE # .t' <br /> } <br /> ----- !f 17 G L�1/ - Efi✓�i�4 "FF ---------- X7 -------- <br /> N - � <br /> 1 CONTRACTOR ADDRESS CA LIC #70 1 CLASS C-6 <br /> T ---------------- �1�7 l -1_---- - o <br /> 1 R °I INSURER ; WORK.COMP.# -- -- -- ----° <br /> IA _____________________________________ <br /> C 1 OTHER INFORMATION <br /> 1 T , _____________________________________________________________________ -------------------------------- <br /> + <br /> -----------; �v �s����� II <br /> I 0 i ° PHONE # <br /> i <br /> ---------------- Lam^ +---------��--ll-/-�-- <br /> C ^`� PHONE #��C/' <br /> ------------------------------------- <br /> ----------------- <br /> TANK <br /> __________________ ( ______________--_ <br /> ANKID # TANK SIZE--'------- �/'T�/ <br /> I /�� w' 'r II CHpF�/ICALS STORE➢ LY/PREVIOUSLY D•i US'C�I/NSI'ALLEL7 <br /> 1 i 39" i 1666[J 5 W,0A li Y� �� <br /> T 39- <br /> A 39- <br /> li N li 39- <br /> K <br /> 9-K 39-39-39-+-"-III!!!I!Mid! 11111ililiiifiiiiiWill!!111liiiilil illi iii 111;111111i lillill1iiiilliiilill1 11 h ill it <br /> Illi! I I ILII I 11 I Il�i°lfllllll I IIIII�I <br /> L <br /> lI <br /> I L APPROVED APPROVED WITH CONDITIONIS) DISAPPROVED ; <br /> A I • ATTR WITH CONDITIONS) <br /> N I PLAN REVIE / A A2T <br /> WERS NAME =41- DATE ^ K~D <br /> ----itlH W i ll11111!1111!1!1 1liiiiililiil11!1!!1111!111 1111 11111111111!1!11111I111111111111Illllilli llillliliiiiiiliiiili M i liiil <br /> 1 I <br /> I° APPLICANT MUST PERFORM ALL WORK IN ACOORDANCE WITH SAN JOAQUIN CCU= ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COMM, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 1 ; 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 l <br /> BECOME SUBJECT TO WORKER'S. P TION SOF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE 1 <br /> I <br /> FOLLOWING: "I CERTIFY THAT I THE C OF THE WORK FOR WHI IS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO ; ; WORKER'S <br /> OOMPENSATTON LAWS OF CADIFORN <br /> i <br /> r . i <br /> Il APPLICANT'S SIGNATURE: TITLE DATE <br /> +--------- -------------------- -- - ------------------------------+ <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional li 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 /> ---------------------- ---------------------------- ------- _----- <br />