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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3"6 FLOOR <br />STOCKTON. CA 95202 <br />APPL►CATION 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 REPAIPJRETROFIT UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT <br />+----------------------------------------------- <br />I I EPA SITE �------•_-------__•"------------- --- .------"----+ <br />-------------��----------------------------------------------------- <br />'-----__ �-PROJECT-CONxACT TELEPHONE $ ----- <br />I F I PACILITY N'am 4�^ '___---- `------`---' <br />( <br />A. • --_•-•_�ls�L. ��J-'----..-..---- -----_ ------ --- �-PHONE-iI--aO�_ <br />I C I ADDRESS I 3 S ' --- - - - - �Y <br />I I --------------- <br />C <br />------------- Q-----------ILS� .� _ V J __------------------------ --------- - <br />--- ------------------------ <br />L I GLOSS STPzET <br />I T I OWNER/OPERATOR PHONE <br />j CArrrxnClo� >KAr>E- - --- --- -----------------------------------------I------ ---- <br />C - -- -- -I <br />I o +---------------- -- - - ----------------------------------------- <br />NI------------- ----- ----------- <br />I CCUORTRACTOR ADDRESSCLASS� <br />T--------------------- <br />R <br />--------- ----" ------------/� l' <br />I ----- � _ C��Y_1�+�-- -- -- ��3;G ._•5___ I ca I.Ic # J�`:h!5� .CS----- <br />R I INSURER may, I WORK.COMP.# <br />. AI------- -- •• --�==�"ICz'--�- }f Y S ----------+--------------------------- <br />----- - - <br />C I OTHER INFORMATION I <br />I -------- ------------ ---------------------------------------------- I PRO-£-- /I�' ' ------ ---_.--_---• <br />O - <br />I <br />R t- -*- - -i ' <br />I PHONE <br />-- I -------...-- <br />= .Y�St^'� i <br />+---Illlllllllllllllilllllllllllllll-----------------------------------------•----_---------------- <br />-`� v �-55 IJ -`r I <br />TANK Ip # i TANK SIZE i CHEMICALS RED CURRENTLY/PREVIOUSLYDATE UST INSTaLL£D <br />39- � <br />T L 39 I --���-7�� I I <br />L A I 39- i4 Z� <br />N I 39' <br />1 it I 39- I I I I <br />I 139- I I <br />�---11111 I III111111111111111 �I�II�,����� � ��� � �IIIIII 1 IlII�IIIIIIIIIIIIIIIIII:111111111111 � � I (111:111 <br />IPI t <br />L I APPROVED>. APPROVED WITH CONDITION I$) DISAPAROVED .. i <br />I A I nI SEE ATTACHMENT WITR CONDITIONS) <br />I N I PLAN REVIEWERS NAME U N- 1" <br />I. <br />IIIII111111111111IIIIII111111111:1111111111111111111 1111 I .II. IITrI,��1�1T1TiTl1l;lDATE l II II(lIIIIIIIIIII1111111 <br />APPLICANT MUST PEPSORM ALL. WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND RECLATIONS OP I <br />SAN JOAQUIN,COQNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES TUE FOLLOWLY3. •I CERTIFY <br />THAT IN THE: PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I $HB.LL NOT EMPLOY AdY PBR5O8 IN SUCH A KANNER AS TO <br />I RECON SU=Cr TO WORKER'S COMPENSATION LAW$ OF CALIFORNIA CoNTaACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE i <br />FOLLOWING: 'I CERTIFY THAT xN TSRH pERFOPAkNCE OF TSE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUH.7EC'T TO f <br />I WORKER'S COMPENSATION LAMS OF CAL -X ORNIA-' <br />t � <br />I / / OJ`_ ' <br />APPLICANT'S SIGNA?C►R$= TITLE �/.(// .ILI�SJ DATE V /yam( - <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 _� ye-_ 7�/�. Address �-6 On n� SttA '*5 Phone # * -60-940 <br />Signature <br />EH230038 <br />(revised 1/31/02) <br />1 <br />