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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 # ICONTACT 6 TELEPHONE _# -PROJECT CO -f <br />I ff ---- <br />Fi FACILITY NAME <br />A/"a C i PHONE # <br />--J- v --------------------------------- <br />ADDRESS <br />----------------------------------------'-----------"---i <br />C I ��� _�:_- (/l/% l SD _ Y------�T ZJ C1V <br />TTT----------------------- ----'--------I <br />L I CROSS STREET <br />T I OWNER/OPERATOR <br />-HONE <br />Y I � GtJ�s Eons f �v�� fs LLC S -o 3 --263 //D I <br />----------------------------------------------------------------------------------------------- { <br />{---+'--'-----'------'--- - J HONE _ <br />{ C I CONTRACTOR NAME <br />,2 / fi��t��N��, �_ s5j ]`esf'Yi j I _P___ <br />�/- ___t_�____ ___ ____________CC _____ ____________---- u____ <br />I O I CONTRACTOR <br />' ADDRESS <br />. r { CA LIC # � 0g 0 l U 1 CLASS ' <br />N ; CONTRACTOR ADDRESS Z/� / a N� �, (/� s� C_!Q t-- H,f Z H !c <br />R I INSURERIi---------------+WORK.COMP.#- 092 GOoe"Ig6;Q�I <br />{ A i ---------J- [L ---W <br />C I OTHER INFORMATION <br />{ I <br />-------------------------------------------------------+--------------'--------'----'---'--'---i <br />101 <br />I PHONEZ- <br />--------------------------------------------------------------------+------------------------------- <br />I i PHONE # <br />+--- <br />____________________ ----------------------- ---- <br />III{��IIII�II��I�I��I��II�II�III <br />I TANK ID # I TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED i <br />I I <br />1 39- I I I <br />T I 39- <br />A I 39- t I <br />N I 39- <br />K I 39- <br />39- -i <br />I <br />I 1 39" I <br />11Hii HiiH iiiili{iilili{I{iilliliiiliiii{ H1 HI{li{IlH Mill I M <br />i <br />{ PI _ APPROVED APPROVED WITH CONDITION(S) DISAPPROVED I <br />L i <br />{ �, '• �„(SEEEy'ATTACtAm�T WITH CONDITIONS) <br />A_ <br />N I PLAN REVIEWERS NAME w „� /l.(/.f� I DATE ~� 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 LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY I I THAT IN THE <br />PERFORMANCE 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." CONTRACT'OR'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 I i WORKER'S <br />i <br />CtDMPENSATION LAWS OF CALIFORNIA." I <br />i <br />I <br />`>G!�'✓L �i ��. F�`'g <br />TITLE �LZr✓ GL CS �� DATE <br />I APPLICANT'S SIGNATURE: <br />---------------------+ <br />+------------- ------------------------------------- - --- ---------------- ---------------------- <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 owner, <br />the party must acknowledge this responsibility for the billing by signature and date below. <br />Name�1��.�L %�trvr.�1 Address/86�_�,/ �Ve�LI� 37`- Phone # ?/y_?62 �z <br />D/ 47J6 e C12 06 -�r- <br />1 <br />