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1-011EC- VIVED <br />Iq <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENTCr 2 3 2003 <br />304 E WEBER AVE, 3RD FLOOR <br />STOCKTON, CA 95202 ENVIRONMENT HEALTH <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT PERMIT/SERVICES <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 />--------------------------------- <br />---------------E#----------- --- ----- OA -N a►�-44� 3� <br />EPA SITE # , PROJECT CONTACT &TELEPHONE # N �ivZC <br />F' FACILITY NAMEQ V M M` i PHONE # <br />A----------------- ----- ----�------ <br />C I ADDRESS 13 V S. L V �+ LN h� ST O fr �h. L Pr ' <br />II +-------------------------------------`------ ---- ----e------------------------------------------ <br />{ L 1 CROSS STREET <br />' I+-------------- ---'- A --- Z 2 t-�—----------------------------------------------------------------------------I <br />T { OWNER/OPERATOR i <br />PHONE # <br />Y I DR <br />lu F �� C.,asz Pr` �v_4�i LLQ ------------------- <br />r1 �4_-(�lg -S3oa <br />---+-------- -�- - y- -- +--------------- <br />{ C i CONTRACTOR NAME { PHONE # 5 + q C <br />.51 <br />0 -------------------- _- _t _ _AV- � _ C -----!-ACT► --�+� N G --------------------------- a9V -— ---------------- <br />N <br />N I CONTRACTOR ADDRESS L I CA LIC # 11r) 17 3, { CLASSA A -z H �c <br />T +-,loSl +H--- - - - --- - <br />--------------------------------------------------------- qQ <br />R I INSURER - ----------j WORK.COMP.#4'OV�SI�UJ ' <br />STATE-�U-~'�------------------------------------- +-------------�-------------- <br />C I OTHER INFORMATION { <br />---------------------------- --------' <br />0 I { PHONE _# <br />I R +-----------------------------------------------+----------------------------------------i <br />-------------------- ---------------- i PHONE _# <br />+---11111111111111111111 11 11111'111{----------------- ------------------------- <br />i� ii i iii ii iii ii i ' <br />{ TANK ID # TANK SIZE , CHEMICALS STORED CURRENTLY/ PREVIOUSLY I DATE UST INSTALLED <br />39_ <br />1 T 1 39- { 1 <br />{ A I 39- { <br />I <br />i <br />N I 39- { <br />i <br />1 K { 39- <br />39-- <br />39- <br />+ - - - <br />9- 39-+--- <br />P <br />L <br />A <br />N <br />_ APPROVED APPROVED WITH CONDITION (S) DISAPPROVED I <br />(SEE ATTACHMENT WITH CONDITIONS) ' <br />PLAN REVIEWERS NAME DATE 1 <br />i <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 LICE27SED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 1 <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 1 <br />1 FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO 1 <br />WORKER'S COMPENSATION LAWS OF CALIFORN <br />i <br />I APPLICANT'S SIGNATURE: ✓ TITLE 4 DATE /o a <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 />Name Z) A0- A u; C ti S F A Address A3N L- T ftt)z;�, L. AJA , 70092 Phone # A fl -44F- " 3°11 2 <br />Signature�'r, 49;r— <br />EH230038 <br />(revised 1/31/02) <br />1 <br />