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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3RD FLOOR <br /> STOCKTONI,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 # I PROJECT CONTACT 8 TELEPHONE # Scott POlSton 925 551-7555 <br /> +_________________________________________________________________________________________________.____________________________; <br /> F ; FACILITY NAME Afoe SmlI a Station#9600 I PHONE # 925 551.7555 <br /> ______________________________________________________________________i <br /> I C ; ADDRESS 1490 North Wilson Way <br /> rI +_______________________________________________________________ ______ _-_________________________i <br /> 1 L ; CROSS STREET I <br /> r <br /> I T I OWNER/OPERATOR i PRONE # <br /> , <br /> 9600 <br /> Y Arco ------t-non---- ------------------------- <br /> C ; CONTRACTOR NAME I PHONE #925 551.7555 <br /> _ _ _ _ __ -------Ryan Inc.__ _ _ _ <br /> N : CONTRACTOR ADDRESS 6747 Sierra Court,Suite J Dublin I CA LIC # 229793 i CLASS a,b,d-10,h=,o57,o61,d40 <br /> T +________________________________ -_______________ ____ <br /> R INSURER State Fund I WORK.COMP.# 428-2004 <br /> C OTHER INFORMATION <br /> T +________________________________________________________________ _________+________________________________________; <br /> 0 ; ; PHONE # 925 551-7555 <br /> r i <br /> PHONE # <br /> ___________________________________rr_____________________________________________ <br /> TANKID # ; TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE DST INSTALLED ; <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> L I APPROVEDAPPROVED WITH CONDITION(S) DISAPPROVED <br /> A w/]--- _/2 <br /> EE TTACHMHNT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE -II!-;OhGS <br /> .... ..... ... ... . iiii,iiii „ ,., ... .. ........ ,.. .r... .. <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 COMPENSATIOWLAWS OF CALIFORNIA.” CONTRACTOR'S HISXNG OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PS RMANCR OF WO OR WHICH THIS PE T IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> ' WORKER'S COMPENSATION LAWS OF CAL IA." <br /> APPLICANT'S SIGNATURE: T LE Permit Expeditor DATE <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 <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> 6747 Sierra Court,Suite J <br /> Name SCOtt POISt dr s D iiN 94566 Phone # 925 551-7555 <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />