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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3"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 REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> ___ _____ ----------------------------------+ <br /> +---, EPA SITE-#-------------------------------- PROJECT CONTACT & TELEPHONE #Ct7 <br /> _ �Iq _ <br /> _ U)-7-71- Z515! <br /> ________________ <br /> +________________________________________________________ PHONE # <br /> F FACILITY NAMECOJ-ww _ ________________________________�µ_ L _' � _____________________ <br /> C ADDRESS t7--A01 � <br /> -5T r Tv J, CA <br /> I +___________ _______________ _______________________________________________________________________________________� <br /> L ; CROSS STREET T>Av13 12-A0I ----------------------------------------------------___________________________________PHONE_#____ __________-_________________� <br /> T : OWNER/OPERATQR <br /> Y C�o.ldw�kiu.as--7(a t3a�ao s>I�. cA asLi ----------------- giG) mss-7fao <br /> i___+_____________ _ +________________________________________i <br /> C CONTRACTOR NAME_J d�_QRJ►11��_________________________________________PHONE # <br /> O +----TRACT------- J _�7 - ---------- <br /> N CONTRACTOR ADDRESS I CA--------------- <br /> LIC # I CLASS <br /> — -_ __ -I <br /> ' T + --- --------------------------------------------------------------------—----------- <br /> R INSURER WORK.COMP.# <br /> A ____________________________________________________________________________________+________________________________________� <br /> C OTHER INFORMATION <br /> +--------- <br /> T +____________________________________________________________________________________I PHONE # _______________________________ <br /> 0 ' <br /> +-------------—-------------- ----I <br /> PHONE # <br /> ----------------------------------------------------------____-------------------------------- <br /> III II'ITANK IDS#' TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- 1 a100o f 'iY lR S tS <br /> T 39- la ouy Z? a� _g' 171f24ALA 06&eRs -/�`D <br /> A 39- to OOf7 O,E50t— /S4 IS 45,A.LUE f y <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> .III I' <br /> P <br /> L APPROVED (APPROVED WITH CONDITION(S) II DISAPPROVED �) <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE f 1V <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN 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 WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY I THAT THE PERFO CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS F ;AL IFP <br /> , <br /> APPLICANT'S SIGNATURE: F / 4 0 TITLE Owca, •#jI"10 DATE 1114 7 <br /> , <br /> , <br /> BILLING INFORMATION: - C lw� `�I -) C& (� ` <br /> %q f4 i czr <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 e*-- T P-14::; a Address -5� C604 A5 �3�••�►���� Phone # <br /> IZoscrl��t.l C/CA �/i SD&t <br /> Signature /'b►/ <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />