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0 <br />SAN JOAQUIN COUNTY <br />9 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 310 FLOOR <br />STOCKTON, CA 95202 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT E%P�iES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />Y�TTAANK RErROF1T _PIPING REPAIRIRETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />----------- ----________________________T________________________________________________f <br />; RPA SITE 8 PROJECT CONTACT _& TELEPHONE q JhmLS�Neu_ ZQ(l_N_jl4i <br />------____________________`__II___-_LL____________-----_�______._- _ _--O <br />F ; FACILITY NAL +' i�Cl �- ./y ---_r+_ t4�1AC__�f'G?r4---------------------- PHONE ----- �----9 L_Z84a-- <br />Af_________________ _ <br />C ; ADDRESS T`yIi"7_ ��" • 4Gcx.%z__.J3_�_ f <br />I l_ial_J- f <br />L ; CROSS STREET <br />T ONNER/OPERATORPHONES _ <br />j r �nI__�j <br />Y : Y /AV � � r i A. A al rn .- i L1 1+AI I ! [.l / <br />C CONTRACTOR NAME <br />A ;`\IT1; YtONSWe_(s'g9CONTRACTORS/1 CA LIC <br />I --------------------- __________-- L%_L__O_O®L _________ <br />i, <br />R ; INSURER ; WGRK.COMP.S <br />--------------------- ._eII_ y____________________ __ _7_z_________`_____________________________________I' <br />C ; OTHER INFORMATION I <br />____________________________________________________________________ f__________----_____________________ <br />0 PHONE R ZQ_63�Q� <br />R __________________________________ y__________L <br />__ <br />; FROM y <br />______________________ <br />TANK ID 9 SIZE ; CMNICALS STONED CURRENTLY/PERVIOUSLY DATE OST INSTALLED <br />39- S -bo- Ky,A. JAj 4? -AD <br />T ; 39- &1OT -M 1 U M <br />A ; 39- DSII <br />N 39- <br />K ; 39- <br />39- <br />39- <br />; L I APPROVED , APPROVED WITH CONDITION(S) DISAPPROVED /I <br />A ; (SEE ATTACHMENT WIT& CONDITIONS) <br />N ; PLAN REVIEWERS RAMS DATE CCX.I�I �� <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 OSPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK POR MICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A WINNER AS TO <br />BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTFACLOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING: 'I CRRTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL RMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPRRSATION LAWS p///O///FCALIFORNIA.- <br />APPL���111IICANT'S SIGNATURE: " TITLE O�t/N �jlr DATE <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 �uiy6ltA#14ealiNr Address hone#Zoy q -3j -2e50 <br />EH230038 <br />(revised 1/31/02) <br />1 <br />