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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3"0 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 REPAIRRETROFIT _UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT <br /> ------ --- <br /> BPA SITE «________ c�c�o -a-- - -- Edyxz,--d� S5q- 5�5-$1 <br /> -------------- <br /> ---------------------------------------------- <br /> P . PROJECI1 TA( THLHPHONE p (' <br /> ___ FACILITY NAME Ct3R____-_____ --��-� __ _ __��V]P80NE p <br /> A .--- - ------ ��--tea 6s ------------------ <br /> - <br /> CADOxeSsar ___l_._+�___ �cX_M__ Ue L -------------------------------------------------------------- <br /> I <br /> '----------- - 1_L CHOSE STREET er__SOLC rQ me n N__Rd------------------------------------------------------------------' <br /> OW <br /> C '- ---------------- <br /> ' T ONNEM/OPERA R PNONH p <br /> I-0111 <br /> Y --- -- 5i �'� S-�- - i-o----1---------- - �-96'T <br /> atil_-4ao <br /> CONTRACTOR NAME --- --- U ---_ - --- __PHONE p Q 1__(050-k9,111----- <br /> R fY <br /> CONTRACTOR ADDRBS E. _ KII IQM,_ masCA LIC_q �I C�'�(..�55CLASS 8 <br /> 1 <br /> AINSURBR3 --__-� _ _____________________ __ _ _________ ____________ __�-W- ----------------------------------- <br /> C <br /> ------ 15- _-_ ------ ___C : OTHER INFORMATION <br /> _______________ -__ ______-__---_-_-_______-_-_-----_----__ <br /> O : I PHONE p <br /> R ___________________ -_-_ -_.._---____----_--__--t---_---_-__ --_- <br /> PHONE It <br /> 6 _____________________________ _________________________ <br /> -- TANK IOlpl 11111111111 TANK 8IZE MICALS STORED C NT Y/PREVIOUSLY DATE UST INSTALLED <br /> 39-�'���' �yp�yqyOE(0�&, y[0L Q4 U iPe <br /> _— <br /> T 39-_ +P+G-�' -_ <br /> A 39- <br /> N 39- - .___-- <br /> K '- <br /> 39_ <br /> • P <br /> L OVED I/ APPROVED WITH CONDITION(A DISAPPROVED <br /> Alc�s (SEE ATTACEISNT WITH CONDITIONS) <br /> N PIAN REVIEWERS NA]4E DATE 0 <br /> APPLICANT MOST PBAP L WO IN CCO 8 KITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAMS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL PARTMBNT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES In FOLLOWING: •I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH MIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> SEMEN SUBJECT TO WORKER'S COMPENSATION :.AWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE 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?�� IAJ�YS TITLE hC'SYIIC/'_`p GATE <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 /> L SKF(Tp�c�(s Ne (L,,-�rp' <br /> Name+k�--jw1 Oz- AddressgOS %nahQ Qqne jh 13Idd. Phone # BoS-31y-Q BOJ <br /> ala �l Ed. , nL L /Jeu� rt3pQr /,3-vo <br /> Signature ` � <br /> S� �*?S9 Oc�t>PCS10�S o� <br /> EH230038 <br /> (revised 1/31/02) 4T <br /> 1 <br />