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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3"D 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 - '6- P4'6 "C tV <br />+---------------------------------------------------------------------------------------------------------------------------------+ <br />' EPA SITE # I PROJECT CONTACT & TELEPHONE # <br />R"iN wt ++6 I-0 <br />1 F FACILITY NAME S�-�eu� _ �c�./Q^ 30 -.2gSO ' <br />1 A +-----------------Q----- ----1--------------------------------------------------I_PHONE-#- 8 - -------------------1 <br />1 C ; ADDRESS L �� ___ �_ � �` MR - <br />1 I +--------------- ----------- <br />L1 CROSS STREET & H-ai R oato W <br />----------------------------------------------------------------------------------------i <br />T 1 OWNER/OPERATOR 1 PHONE # <br />Y 1 0&a V� (ka. .�o �.1tiS o �1 A0 Q — � 30 -��c So <br />1--+------------------------------------------------------------------------------------+---------------------------------- ----- <br />C I CONTRACTOR NAME ��� ��(M S 1y`� 1 PHONE # 40 g - 3 _ 03 e ' <br />iO -------------------------------------------p-�-�-�-------- <br />1 N 1 CONTRACTOR ADDRESS_&o Ql�� I"Vl'�.. S� 9 lta. , CA LIC # 4g�/ ?Li , CLASS «cl /D+{6 AAT_ tl (G <br />1 T -------------------- --------__-_--------------'�--------------------------------------------------{-----'1 -------------------1 <br />R1 INSURER } '� - WORK.COMP.# <br />A1----------------- =�--- ��`-----------------------------------------------+---------------------------------------- <br />C 1 OTHER INFORMATION <br />i O PHONE # <br />iR+------------------------------------------------------------------------------------+----------------------------------------1 <br />i <br />PHONE # <br />---------------------------------------------------------------------------------------------- <br />TANK ID # TANK SIZE 1 CHEMICALS STORED CURRENTLY/PREVIOUSLY 1 DATE UST INSTALLED <br />39- <br />1 T 1 39- ' <br />A 39- i <br />N 39- <br />K 39- <br />39- <br />39- <br />P <br />9 -39- <br />39- <br />P <br />1 L 1 APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />1 A 1 �Q (SEE ATTACHMENT WITH CONDITIONS) <br />N 1 PLAN REVIEWERS NAMEDATE -06 <br />iii iiiiii.iii.......... <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF 1 <br />SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT INTHEPERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO i <br />BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING: "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 LAWS OF CALIFORNIA." <br />i <br />APPLICANT'S SIGNATURE: �' �L.-L,�.-�LLr� TITLE <br />��'Y'Y�(Q��'� S,4& DATE �baa< fp i <br />+----------------------------------'1_{LIS------------------------------------------------------------+ <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 />Namel­(ARV[('�')• (>`;EMRW Address6W&otwA Aq-e_ %P- &e, 7VIa.Phone# 46t -913'46"W <br />Signature lu U . <br />EH230038 <br />(revised 1/31/02) <br />1 <br />