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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />dOa E WEBER AVE. 3Fu FLOOR <br />STOCKTON. CA 95202 <br />APPLICATION FOR UNDERGROUND TEAK RETROFIT, OR PIPING REPAIR PERMIT <br />TMS PERMIT <br />EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMR TYPE BELOW: <br />----_ X TANK RETROFIT _PIPING REPMRIRETROFIT _UNDER DISPENSER CONTAINMENT REPAIFURETROFFF <br />BPA 6ITN N c�R___Qd�_ iy a7Sl.P�cTcavTAcr <br />_6 TNLBPHCNB-N F�,L.A)OLrQS___�5 •_ ��-g�S,6 <br />---- -- �I_r. PHONE N <br />P NAM ��r1 _ <br />_____ ---__ <br />ADDRESS I�-------------------------------------- <br />1__ <br />a N1 a")r <br />L : CEDES STREET __ <br />I+______________________________________________________________________________________PHONE M$o__5_ a)�!-_ 9 a�_�_�_-iba <br />T OMYER/OPmN[fOR A 9 1 _`, _ ________1______________________ ________ <br />Y UJSSR1_ --iT T1l---- Yi1 1 _ ---r'IDYi_ _______________ _ <br />C ♦ CONTEACNR NAME l N-Qr'SU[�'YIO %7 I____, <br />O -------------------- 4�`^ -1 , �((CC CC 1 A- <br />------------- <br />/I / <br />N CONTRACTOR ADDRESS r.A L �T�Tw CLASS A- i'r'IC <br />�_ . y_____ - �_I`J_,S____CA LIC_»_______ <br />____ ___ ________. --RK_w--_M_I____- _ <br />5 E leR K}ue �an_1�' _-- <br />R INEUREA p0rea---- MP'-- --`fix---- c' FJIII a' ----a Oo3 <br />A <br />C OTHER INFORMATION <br />_____________ ____ <br />PHONE # <br />O_____________________s________________________________________� <br />yi+____________________________________________ _____--- <br />PHONE It <br />------- <br />._________________________________________________ <br />____________________________________ <br />ITANK IDYI I.....,TANK SIZE C i Ls S -RD 6NTLY/PREVIOUSLY DATE DST INSTAI,B <br />1' <br />39- e <br />T 1 39- <br />A I 39- IV /I1 - C_ M <br />IF 39-iQSC - <br />A 39- --- <br />+ 3 VIII APPROVED (SEE APPROVED WITHCONDI <br />CONIDIUM (S) DISAPPROVED <br />P <br />L <br />A ATTACHMENT IONS) 7 / <br />R <br />PLAN REVIEWERS NAME ... DATE / _O <br />APPLICANT MIST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF ' <br />SAN JOAQUIN COUNTY, REVIRONMENTAL HEALTH DEPARTMENT- OWNER OR LICENSED AGENT'S SIGNATURE CERTIPISS THE FOLLOWING: 'I CRRTIFY <br />THAT IN ME PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT SNPLOY ANY PERSON IN SUCH A WANNER AS TO <br />BBCOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />MO IMG: '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 '.YAWS OF CALIFORNIA." Jj1-/�-����p��� <br />1 / .�I <br />APPLICAYT'S SIGNATURE: �3---_-_— - TI �� V DATE �g lq-:.NT <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 />az <br />EH230038 <br />(revised 1/31/02) <br /># SOS-41+0i"Il <br />