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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 REPAIRIRETROFIT _UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT <br /> __ ________________ -* <br /> BPA SITE q ____-----� PROJECT CONTACT fi TELEPHONE « --pl-I -- - 554- 583-3�•3� <br /> *_____.___ 1 n MHE # <br /> --- �--� <br /> P FACILITY NRB U I.JT� AA <br /> �M <br /> C ADDHESS GI.'�1 O N . M!� I ST• M a.Nrr�c.a- C A' <br /> I *-------------------------------------------------t-----------------------------------------------------------------------I <br /> L caoss srneEr A.•l-P M F-c d/�- $r. <br /> I *-----'-------------------------------------- -- - <br /> T T I OWNER/OPERATOR PHONB # S 3 32 <br /> Y 1 u ern o nn Pi�-I 685- W . 3ld sr.I �Ic nlFonfJ,Gig' S p4l- $ 36V <br /> I---*------"---- ---------I <br /> I PHONE « I <br /> C I CONTRACTOR SAME '(,7 '&*, i!r> S "`I`• <br /> _ _______________________________________________1 <br /> I N I CONTTACIOR ADDRESS CA LSC # I =ass <br /> ____________________________________ <br /> T *____________________________________________________________________________________ _WORK.COMP.# <br /> I R I INSURER <br /> *________________________________________I <br /> C OTHER INFORMATION <br /> ___________ _ _______________________________ <br /> _______________________________ I Px # <br /> DI <br /> PHONE*_____________________________________________ ________________________ _________ <br /> g <br /> ___IIIIIIIIIIIIIIIIIIIillllllllllll______________________________________________ ________________________ .______ <br /> _ _ <br /> TANK ID # TANK SIZE CHEMICALS STORED CVRRENTT.Y/PREVIOUSLY iDATE UST INSTALL® <br /> 1 14 000 81 of C�AseLIVcI unk-n <br /> ilow(.l <br /> jT j 3939�—I 4 00 o CO C—�PEO611 GAsnlNy UNwNowr.] I <br /> A 139 I 1 <br /> IN I39- I <br /> K 139 I <br /> 39- 1 <br /> 39- 1 <br /> ,___I 11111111 II III IIIIIII l Sill SSSS 1 1 1 111 11 1 1 lil 1 1 1 11 1111 l 111 111 l 1111 l 111 l 11 l 11 l 1111 111 1 1 11 1 1 1 111 1 1 1 1 1 Sill l 11 11 11 1 1 1 1111 111 l SSSS l ll <br /> P1 <br /> L _APPROVED APPROVED WITH WNDITI@1(S) DISAPPROVED <br /> A (SEEATT/A/�@��.WITH COMIDITIONS) /D r I <br /> N PLAN REVIEWERS NAME �L V/)L, DATE u 1 <br /> +---IIIIIIIIIIIIIIIIIIIIIII II 'lIIII Illllllllllllilllllll IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIII <br /> APPLICANT MUST PERFORM ALL WORK IN ACWRDANCE WITH SAN JOAQUIN COIRTT'1[ ORDINANCES, STATE LAWS, AFID RULES AND REGULATIONS OF THAT IN THE <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATTI <br /> URE CERTIFIES E FOLLOWING: "I CERTIFY <br /> PBRPORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL RCT 6MPIAY ANY PERSON IN SUCH A MANNER AS TO I <br /> BECOME SU,,IECP TD WUAFEA'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBNNTRACTING SIGNATURE CERTIFIES 1IE: WORKER'S <br /> ',,=WIND: "I CERTIFY THAT IN THE PEI OF THE WORK POR WHICH THIS PERMIT IS ISSUED, I SHALL EM y PERSONS SUBJECT TO <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> I / I <br /> .X70 <br /> APPLICANP'S 3ICI.ATURE: <br /> TITLE / ' DATE <br /> ,a f�^a� �H �'-----e-4 --36yy <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 owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name IW,) VAGr" Address 6 uJ • 14•rLD sr. Phone <br /> AA <br /> i <br />