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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,fo 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 A ; PROJECT CONTACT S TELEPHONE N 1`A - A�j <br /> ---------------------------------- <br /> ' F ; FACILITY NAME n(. !0 ; PHONE R ' <br /> 1 1L `� )M'�S" <br /> p - ------- --------------------------------------------------------------------F----- <br /> -- -------- <br /> C 1 ADDRESS /n 1 V0-�---H �------------------------ -------------- ' <br /> YYY,,, -- - �-- - ---------------1' <br /> L ; CROSS STREET <br /> ------------------------ ---- <br /> T ; OWNER/OPERATOR ; PHONE X <br /> Y ' 6P (.�1 E5� Co AS- D,tio D. c—s ( lL '1 14 1,70 �3a� <br /> _ ---------------------- <br /> C :; CONTRACTOR NAME S. .� W:A L .-Q ,-1 A C�i -I-(�cr-------------PHONE B 7 1u�_.a�'IU_=_0 U 5�------�----- <br /> -- <br /> N ; CONTRACTOR ADDRESSCA LIC 8-- -1�1� -----CLASSA�NA Z <br /> (�- WORK.COMP.R <br /> R ; INSURER S A6 oou�45,-_03__--- <br /> S–( <br /> A�� ` -, <br /> C ; OTHER INFORMATION ' <br /> ---------------------------------------------------------------------------------i- <br /> O ; PHONE R <br /> ---------------------------------------------------------------`- <br /> PHONE k <br /> -------------------------------'--------------------- ,---- <br /> TANK ID R TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 3 9- <br /> T 39- <br /> A ; 39- <br /> N 39 <br /> K 39- <br /> 39 <br /> P ; <br /> L APPROVED _APPROVED WITH CONDITION(l DISAPPROVED <br /> A (SEE jTTACHMENT WITH CONDITIONS) <br /> DATE <br /> N PLAN REVIEWERS NAME <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS QF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER CA LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTEFYTHAT IN THE <br /> PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY AHBSON IN SUCH A MANNER AS TO ; <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 WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> ^,'l .) <br /> APPLICANT'S SIGNATURE: TITLE A Q DATE 6 <br /> --------------------------------------------------------------'+------ <br /> BILLING INFORMATION: <br /> 111 1 <br /> IV- <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 Address Phone# <br /> 1 <br />