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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3M FLOOR <br /> FSTOCKTON,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 I_1 PIPIINN'G REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIRfRETROCF�-- �JL �- S <br /> BPA SITE - I.y 33/3 PROJECT CONTACT 6 TELEPHONE p�pri -E(4,U,JQ�-Q,S �J ' m---------- - <br /> ___ __. ]]91yy PHONE.N <br /> P FACILITY-1. , V_ ----_ I -_ - ----- <br /> A - ` I / (� 1 -- <br /> I C ADDREBS �' ry-� yam. �\ �UC�_ I l��l rl�/J_- ------------------------------------------------- <br /> I <br /> _ ____ __ __-_ _ <br /> I ._CROS____ _ __________________ <br /> L -----TREET_(_,owes__SOLCreLr�'1Pn __Rd_,_____________------------------------------ <br /> T I OWNER/OPERA R I I PHONE bs ';IIq--- <br /> '-Y-'-COEW--------- C --OnO.-----'N S -- CSF_ r0. iJn----------------_---�s_�171•S 3b171------ <br /> y)SK1__�Csa -Ir PI)- <br /> C CONTRACTOR NAME U I1 <br /> R _____________________ '�/ ICS 1I <br /> N CTOR ADDRESS) _ -E.___l�l IP,,_ g_Ue.ScY np.IrCLS- CA LIC b L�__------------------ <br /> CONTE. 'J � P� <br /> A ____ _ _ _YO'{T�.yl�� WORK.COMPA <br /> T INSURER� �... 1 l�Q/� a__________________________________________________________________��� <br /> C OTHER INFORMATION _______________________________________1 <br /> T _______________ <br /> PHONE p <br /> O __________________________________________________________ <br /> PHONE p <br /> . .. �., ______ ___ __.___ _-__ <br /> TANK ID If TANK )ZE C MI CA-S STORED <br /> �yC.U�[1Rp1E1pNgT Y/PREVIOUS V GATE UST INSTALLED <br /> 3903 ii3� oSIrO �ob _urOo pdn, 4dr�_.S1-n14Li -- <br /> A 39- <br /> T <br /> 9 V _ _ <br /> N <br /> K 19- <br /> 39 <br /> GATE <br /> P <br /> , APPROVED WIT" 'ONDTTIONI <br /> A ATTACEMEN) WITF CONDITIONS) <br /> VED • DISAPPROVED <br /> (SEE AT <br /> A PLAN REVIEWERS NAME <br /> APPLICANT MUST PERP L NO IN CCORDEWITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL N PARTMENT. OWNER OR --CENSER AGEM"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 <br /> TO <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CBRTIPIEE THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PBRFORNANCE 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 SIGNATURB?` �rI-� �S _ _ TITLE DATE _ <br /> 3 alms <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 /> L9.$YkCTEA.x�(-Ne �r� <br /> Nameo-a+k�-131ct4- Address90, /i=hG4nelbii id Phone# �oSai aoo <br /> IJe�b r5�r1�, YJ� 1310 <br /> Signature . �r�._ � 3 <br /> EH230038 5 <br /> (revised 1/31/02) - <br /> i <br />