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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 _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT -+ <br /> +--------------------- -------------------------------------------------------- <br /> EPA SITE # -PROJECT CONTACT & TELEPHONE # - ----------------------- <br /> ------------ <br /> ------- -------------- <br /> +-------------------------- ---PHONE # <br /> F FACILITY NAME--3`�----------------------------- - ----------- <br /> C ,arc------------- <br /> -- ---------------------------------------- <br /> C <br /> - -------- <br /> A +-------------- J� f U / g524o <br /> C ADDRESS & 1. ��C�CL�C - Y—_ -t---- ------------ <br /> - -------- -- <br /> L ; CROSS STREET W q q____----------------- <br /> t ' <br /> I +----------------- n PHONE # <br /> T OWNER/OPERATOR 16'1, y �I` I <br /> I---+---------------------------- - - <br /> - ----------- - <br /> - - l PHONE # Z SS ' <br /> C CONTRACTOR <br /> NAMErC]�i�- L�LL������Lrss-s--, --------- -------- ---y----------�---- -�-�-- -/ --(J-/-�--{ <br /> N + CONTRACTOR ADDRESS( 6-_Si� --WV'Lf�_ Jl�- j---------CA-LIC-#-2 �"13-------CLASSf���_ <br /> T ----------------------��IIIIJJJJ J- <br /> ' WORK.COMP.# <br /> R INSURER �y�t ' -_- �"I(iV___ --------- <br /> l]1Gc L�arr_`IIIIAAJ --------------- <br /> C OTHER INFORMATION +----------------------------------------� <br /> T +------------------------------------------------------------------------------------i PHONE # <br /> ------------------------------------------------+- <br /> R +------------------------------------ PHONE_# ' <br /> +---; Illillllllllllllll' ,, ,, ,,"' TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED <br /> TANK ID # <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 1 39- <br /> 39- <br /> 39- „ <br /> P ; DISAPPROVED <br /> L APPROVED APPROVEDIWITHICONDITION(S)� O_�� <br /> A I - r (SEE ATTACHMENT WITH CONDITIONS) _ DATE YJ <br /> N PLAN REVIEWERS NAME �•JG <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 /> AWS O <br /> F THE WORK FORWHICHTHIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> FOLLOWING: "I CERTIFY THAT IN THE PION L <br /> WORKER'S COMPENSATION LAWS OF CA ORN A." (�/� .A�/� <br /> TITLE�Ca&ttf E C-1(/IL- DATE <br /> APPLICANT'S SIGNATURE: <br /> -------------- <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 <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name �fzcP�.•J C� Address ' 6� �iCApA ( 4E ' Phone # ! > ) <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />