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0 <br /> 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 IRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> _TANK RETROFIT_PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT <br /> t_____ _______________ _____________ _______________-____________ <br /> EPA SITE # ! PROJECT CONTACT 6 TELEPHONE #Du,('� faneti 2o9-' toy-ZoI� <br /> — kita5b0---- �j�/_93i- (PlS'f <br /> F ; FACILITY NAMEC ----��x � � 1—_• ���s_""_ __- ! _v"'_L" - "____��ZI I__________________________________________� <br /> CROSS <br /> STREET <br /> 15 <br /> L ! -' , �r�Y1TR _______JAL`^"'• _ -- 1------------------------------------------------------------ <br /> T <br /> Iv_____________________________________________________! <br /> L --------------------------- <br /> T ! OWNER/OPERATOR <br /> !--------- <br /> PHtONE # <br /> __ t_____ ______- <br /> ' <br /> ✓ <br /> ----------------------- _ ________r <br /> O ' CONTACTOR_ _ __yXPHONE # <br /> _-hied____ ---------------- `- <br /> N CONTRACTR ADDRESS (�S- " ! <br /> _ CALIC # <br /> T _ ____ � ___ <br /> _______i _ HORKCOMpR INSURER � 4L rUK___________________________________ _____A ____________________ - __________ _ _ ---- <br /> C !! <br /> OTHER INFORMATION <br /> i PHONE #-7n9----- <br /> 0 ! YX __J_ <br /> r <br /> PHONE # <br /> t rrrrrrrrirrrr ri rrr rrrrr rrr <br /> rrrrrrrrrr ii!____________ ________________ <br /> rrrrrrrrrr rrrrr rr rr r <br /> TANK ID # TANK SIZE ! CHEMICALS STORED CURRENTLY ! DATE UST INSTALLED <br /> 39- / I�O1J C I.lY1 Le[I CIQ•(1 <br /> T ; 39- Q- <br /> A 39- <br /> N 39- 7 AnJ <br /> K ; 39-_ <br /> 39- <br /> + rr rrrrrrrrrrrrr,rrrrr.rr rrr.rr r.rr rrr rrrrrrr rr rr r........ .. .,/y�`I['I� r.rrrrrrrrrr,r rrrrrrr rr rr rr rrrrrrrrrr rr <br /> A r rrrr.rrr'r rAPP DYED SBS APPROVED WITH C NDITION I'SOP ) DISAPPROVED�r rrrrr ��rr rr rrrr rrrrrrrrrr <br /> ! P <br /> COND <br /> r ROVE <br /> 0 <br /> N PLAN REVIEWERS NAME DATE <br /> rrr O <br /> t___rrrrrrrrrr r.rrrrrrrrr,ri rr rr rrrrrrrrrrr rrrrr rrrrr rr.rrrrrr rrrrr rr r,rr rrr rr,rrrrir rr rr.rrrrri rr r,r,rrr <br /> APPLICANT MST PERFORM ALL WORK IN ACCORDANCE WITH S JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE NO K POR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> BECOME SUBJECT TO WORKER'S CO TION LAWS OP CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN TH HRFORMANCH OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF I RNIA." <br /> APPLICANT'S SIGNATURE: TITLE DATE <br /> uji c" ' -- <br /> 'neer <br /> ' -- <br /> BILLING INFORMATIO : <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 11 5�� NI i Address lg <br /> �WN IV- H'V 191 ' Phoneopq-7Yn-% <br /> �ySignature � <br /> EH230038 <br /> (revised 1/31/02)��� <br /> 1 <br />