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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3RD 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 />{ I EPA SITE # i PROJECT CONTACT & TELEPHONE _# i <br />+----------------------------------------------------------------------------------------------------------'------------------ <br />F <br />--------- <br />{ F I FACILITY NAME I PHONE # - ---i <br />A +----------------- --- �.�--- --L- c. [^D_ __ -` -- ��--�- ---- <br />{ C I ADDRESS <br />1-------------------------- <br />L { CROSS STREET <br />I .���SS`SL1["/ ---k 1`- —_ <br />----- ------- --------------------- I-------- --------------------------- ---- <br />I ---------------- ---��----'� <br />T OWNER/OPERATOR PHONE # <br />Y �'-� o <br />---------------------+---------- - ---------------- <br />I---+- <br />ii <br />{ ------------------------------------ <br />c { CONTRACTOR NAME- A�Q� (r /� C0 �C 7 r� PHONE # �Lv X13 _ �' _ _ <br />j-------- _ ------ ---------- <br />N CONTRACTOR ADDRESS I CA LIC #�_p CLASS <br />T +--- ------ tli----6- 1__u_SS L�/G Qv_1 -5 ------------ ----------------1 <br />---------- -- --------- ----------------- <br />- <br />R I INSURER WORK.COMP. <br />I A I------------ <br />C��'- -� _�---�---------------------------------{ � _moi Q�1�Pi�Ct-_ I <br />{ OTHER INFORMATION 1 <br />TO1----------------------------------------------':------------------------------------+-PHONE---- � yi-C-------- ---------------i <br />------------------------------ ------- --- - - ---'-- - <br />1 I PHONE -# <br />+ 1111111;111;1111111{1111;1;1111--- -----------------------------------------------------------------------------------------I <br />1 I TANK ID # ; TANK SIZE { CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED <br />{ ; 39- I I 1 <br />1 T 1 39- <br />{ A ; 39- <br />1 N I 39- 1 <br />1 K 1 39- <br />39- <br />39- <br />P <br />9_39-39- I { <br />1 i11111111ii;1111i111111i11i 11;;;;{i;;;;i111111i;'11{;;{;;1{;i111;{1;;11i;1;;;1;i;i;11111;;;illi;;{111111{I{1;;;;;1ii;;;{;; 11; <br />L I APPROVED APPROVED WITH NDITION(S) DISAPPROVED <br />(SEE ATR'P.'CFBdENT WTfiI�NDITIONS) <br />PLAN REVIEWERS NAME <br />11111111;1111111;111MUZMME <br />•' i <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNt7-OFiDI*ANCES, STATE LAWS, AND RULES AND REGULATIONS OF I <br />SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY I <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 I <br />BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />i <br />FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATIOWLAWSOF FORNIA <br />APPLICANT'S SIGNATUR <br />I II- <br />I TITLEC( j:lf0 � ��I C(C(/TL DATE <br />{ <br />I <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 />0 S'LCL-, Address (e ,z C,, Lo v Phone # <br />Name K <br />Signature <br />EH230038 <br />(revised 1/31/02) <br />I <br />