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!°/14/LUU4 1O:ny Z11y4bU3433 FIFTH FLOOR PAGE 03 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,eo FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES SO DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT _k1PING REPAIRIRET_ROFIT_^UNDER_ _ _ _ _ <br /> DISPENSER CONTAINMENT REPARSTROFIT <br /> ___________________ <br /> ____ _______ ____ _______ ___ ____ _______________ ____ _I W_______ <br /> I SPA SISB a I PROSECT CONTACT A TELEPP-ONB a I <br /> ___________________________________-----------------------------------------------------------___. ..q.._......._____ ---------- <br /> F I FACILITY NAME ,\ �- I PRS 0 <br /> IR. 1 <br /> C I ADDRESS _______ ..QLD___-_l.-A'l`.�l..T_ Y-.Q1A__________________________•_-------------------------------------- <br /> L <br /> .._____-. <br /> T .----------------J-aka- ._._L::zi .�- --_. --------------- - -••-----------_-- -•--------i <br /> L 1 CROSS ------TREST l ' <br /> I T I OWNER/OPERATORPHONE a <br /> 1 Y I r <br /> C I COMPACTOR NAlOi r t YRONs <br /> - - <br /> I N I NPTRACIORADOHEss \-UPJ -J(p OV'�h�Ov1----�•cAsxca..�tf��� ---1 cwss QTrL- I <br /> I -----------------�-------�-I- ---- / -�-1%.Q _ ( -.----- -------------i <br /> A I....._._____uSJ..-See_L!_I_rKDI'1_k1[ST�W.. 21___<... _______________________________________I <br /> I R I INSURE@ 1 IIORK.COMP.a I <br /> I C 1 OTHER LNFORMATION I <br /> T ------------------------------------------------_____----______--- ____---__-___.-----� @.---_______------_________--- -I <br /> ' R -__------.____________________________________________________________________________________________________________________fl <br /> ---IIIIIIIIIIIIIIIIIIIIIIIIillillll_____________________________________________________"I-- --p_ ----_.._____----_-___-__._...-.I <br /> T ID a TgNR$IK8 0MICAL5 STORED GORRKWTLY/PREVIOUSLY I DATE UST INSTALLSD I <br /> 3B- <br /> A 39- I <br /> R 3q.- <br /> 39- <br /> 3 <br /> 9•39- I I <br /> ---11111 I I 111111 IIIIIIii,il111111ii9- <br /> Immilm1111I1. 71IIIII,i,1I1111 I,IiI11111 Illllllli <br /> IPI <br /> I LI _ APPRO�IFL APPROVED WITH I -�, DISAPPROVED <br /> A I TS—E-9ATTAATTACHMENTATTACHMENTWLTH CONDITIONS) DATE i <br /> R , PLAN REVIEWS@9 NIJ <br /> 4---111111iIIIIIIIIIIIIIITIF ti—FTiIIIIIIIIIIII 1111111 { ILII IIIi„ 11111 , 111111Ii ImiIiiii111Hill HIM llil illlllllli I <br /> I II APPLICANT MUST PERFORM ALL WORK IN ACOORD,VICE WITH SAN JOAQUIN COUNTY ORDINANCES, STALE LAWS, AND RULES AND REGULATIONS OP <br /> I SAS JOADUIN COUNTY, ENVIRONMFNS'AL HEALTH DEPARTMINI'. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE ]FOLLOWING: -1 CRtTIFY <br /> 1 THAT IN THE FERFORM . OF THE WORK FOR WHICH THIS PERMIT TS ISSUED, I SHALL NOT E@LOT ANY PERSON IN SUCH A MANNER AS TO <br /> I BECOME sUBJECr TO WORKER'S COWPEISATION LAWS OF CALLFORRIA.. cONTMCTOR'5 HIRING OR SVSCORTRACrING SIGNATURE CERTIFIES THE 1 <br /> I FOLLOWING: "I CCRTIFY THAT IN TH£ PERFORMANCE OF TRE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL FMPLOY P8@SONS SUBJECT TO <br /> I WORKER'S COMPENSATION LAWS Of CALIFORYIA.• <br /> I I <br /> I <br /> I APPLICANT'S SIGNATURE, TITLE DATE <br /> I <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit paymen <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. propert%, <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name 1.0 D � Win- Address 14(3 4MA . � �^' Phone# �I�l�- tS�7 J <br /> Signature <br /> EH230038 " �VE D <br /> (revised 1/31/02) <br /> OCT 18 2004 <br /> 1 ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <br />