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10/16/2002 15:48 2094683 FIFTH FLOOR PAGE 03 <br /> 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 ___PIPINGS REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> }--------------------- <br /> I I EPA slrE a ------------••----------------------------------------+ <br /> TSLEpMO <br /> I t-----------••---------- ----------------� PROJECT CONTACT --------- -- <br /> -�-'- - •--------------— ...... <br /> -1 <br /> I F ' FACILITY NAM Tj/�� lie-------- <br /> A L�� <br /> - `� - -- - - - ------------- FMWE 3 kH <br /> I <br /> C I - -- - - -- - - ------------- ---- - <br /> 1 sit �b <br /> A>:�5 61 t�(2 N A wt� - Q - ------------ <br /> L 1 CROSS ------ �ArAM EP• L+k/iu - - - <br /> -•I <br /> _ __________ ______ <br /> 1 T I OWNER/0R8RATOR - "" -•--I <br /> I �? St PtiDNE f <br /> Y - ---- aS -- �K--D- C. :S - LLC, I �1 <br /> f---+----- -- - - . 6�-.5-if i <br /> I c 1 carrrRncZeR NAME -----------------+-----•--- <br /> P� Ov% - -- <br /> - <br /> ------------ <br /> IO .------------------------------ T�ch�-- eS I c Pf OL4E <br /> N I CONTRACTOR ADDRESS _________- .._) { -- /-1 •--- 1 <br /> T +___...._____________ s. Tl1 ►Nth Av�- <br /> CA tic It <br /> � I <br /> R I INSURER--..C .�.p f� J ---[-�-L---I--J........C1- - ---I <br /> i A I------- -- - ---r�_ a i`_ 1'V✓IGl I wb---X.mra--p- ---O�•U''_I� 1gO,,63 <br /> I C I OTHER INPORMATION _____ <br /> IT • ----- ---------- <br /> - -- - -- - - --- •` - <br /> I 0 I <br /> g <br /> R y________________________________ I PRO14E <br /> I I <br /> y---11111 11111111111111111111111111-------------•----------------------,._...___----------PF;Obm-n-......-„--„- <br /> I I <br /> TAN.- .10 p - - - - - - ! <br /> TANK SIoB 1 CHE6tICA.L5 STORED CMRF.NPLY/PR vi00SLv <br /> 39- <br /> I OATH UST INSTALLED <br /> I 1 <br /> I T 39- <br /> A I 39- <br /> N I 30_ I I <br /> I K 1 -,i9--_j <br /> I I I <br /> I 139- 1 <br /> i <br /> ---;II{1111111!Illlllifillllillilillllllllllllllll;llll'IIIiIIIliilllllllll h 1111;llllllllllllllllliiliilllllllllfl;lllllllllllll <br /> i P I <br /> L I QED V/1 <br /> PPROVED WITH CONDLTION(S) DISAPPROVED <br /> A I ( H TTA WITH OCNDITIOWS) <br /> N I PLAN REVZAW4"'�S NAnss -0 - DATE <br /> '4-• Illilllllll;IIIIIII!IIIIIIIIIIIIIIII 111,1111'IIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII111;11;11111 II;IIIIIII11111111111 <br /> I <br /> ' APPLICANT MUST PERFORM ALL WORX IN ACC04DANCE WITH SAN JOAQUIN =A+Fx ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OP <br /> I SAN JOAQUIN COUNT X, ElNIR0N?-04TAL HEALTH DEnARTP"T, OWNHR OR LICENSED ACBNT'S SIGNATURE CERTIFIES THE FOI,Lgc4II7G: "I CERTIFY I ; THAT LN THE <br /> Pli FORMANCE OF THP WORK FOn WHICH THIS PERMIT SE ISSUED, I SHALL NOT EMPLOY ANY F=N IN SUCH A VAMII7ER AS TO I <br /> 131-=C SU3JECT TO WORKER'S COMPEI4SATION LAWS OP CALIFORNIA.^ CONTRACTOR'S MIRING OR SUHCM ACTIW-SIGNATURE CERTIPIES THE <br /> 1 POLIAWTNC: "I CERTIFY TI•AT Id THE PERFORMANCE OF TAE WORK FOR HRICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO ! WORMR'S <br /> COKPE24SATTMI LAWS OF CaLIFORNIA." <br /> I I <br /> I <br /> I <br /> I <br /> APPLICAN'T'S SIGNATURE: TITLE LIp <br /> DATE O ' I, <br /> -------------------------------- <br /> BILLING <br /> "'.c w4" ie-'ze <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 forthe billing by signature and date below. <br /> Name Address _Phone# <br /> 1 <br />