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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE.3""FLOOR <br /> STOC;KTON.CA 952()1 <br /> APPLICATION FOR UNDERGRUUNU TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 9U DAYS FROM THE APPROVAL DATE UU NOT WRITE IN ANY SHADED AREAS INDICATE PERMIT TYPE BELOW <br /> _TANK RETROFIT _PIPING REPAIRIRETROF;I _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> EPA SITE p ( Pku.l El—I' I'ON I'A-':. y 'I'E'..H I'HON F. n { <br /> . C�-'� �� ��a �(�(� a1 ._�o�- lF, �-101 <br /> F' FACI:.TTY VAMP_` e,\(,-/{ ( f„ E If <br /> A �- � ` ' .� y +,}r}3�O yy��v/�y� ' `� n (/� PHONE ply ADDRESSI�1 1 a L V� f)G I 1 L/ .lam �L1�y 7 <br /> CROSS STREET <br /> ------------ <br /> U,, rp it PHONE <br /> /// it ��, �nt.G`�^1Y1FF,`-.�,-a�l-'i Tri -a tO-q.-L <br /> "ONTRACTnl+ NAME ��'` ���-ll�! 1 p <br /> _ (� _ PHONE �Ir}/-�/_ Cfnj� <br /> "ONTRAC'!`. 4 AUUR ESS l F-, �'G7h 1 •T�JI�.l `-�..(..1�L.711)I.t�A ..•+' q 1 I (+`E ISS -.ASS <br /> R INSURER -��/'�1�, 1 <br /> A <br /> WORK.C'OlIP. <br /> �' INFORMATION <br /> p 15-7 /I c-Q _9 <br /> OTHER f NFUHMA'I'I UK -- - - / __ <br /> T __ <br /> n <br /> " -- PHONE p <br /> --- ------- <br /> PHONE p <br /> 1y/1,� r�T K '{+'M STORF.0 C'URRRNT:,Y/PRRVTOUS:.Y DATE UST INSTAILED <br /> A U' " �.Pn I.�acl ��l► �,e- _ ___ <br /> N <br /> K <br /> 19. <br /> F' <br /> /,.E A'ITAf_'HMN.h': .r"I'I '•IKIiI'('I+)NSI ,)I SAPPROVED <br /> PLAN I EW F:-.; NAMF. (, at coWJ�/� <br /> ;,ATF. <br /> APPLICANT MIIS, "F4F'IRM A:,- WUHK :h ACCORDANCE. WJT14 SAN .R)AUU1". .'"N Y ,'.uDINAN[•Ny. STATE: .AWS;, AND RU1.Et, M1U <br /> SAN JUAQUIN I')UNTY, ENVIRONMENTAL H&A-TH UEPARTpW I IMINER <br /> THAT IN THE PERFURMANCF: UF' THE WORK FOR WHICH THIS PERMIT I''ENSEU AGENT'S SIGNATURE �.'E'RTIF'1ES THF: F'UL..UWI NG..NT.1)hl_ )F <br /> BECOME SUBJECT TU WOR1(E;+':: CUMPENSATION :.AWS OF CA:.1FORN1A; �I�D' 1 SHA:.:, NOT gi1PLUY ANY PERSON IN SUCH A KMKIKk CERTIFY <br /> TO <br /> (CERTIFY THAT IN NTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> THE PERFORMANCE OF' THE WOkK Flr rIk ICH TH 2:; PERMIT IS ISSUED, <br /> WORKER'_^, COMPENSATION :.AWS OF UA:LIFI)RNIA " <br /> . :;HAL:, EMP:w?Y PERSONS S[iBJ ECT TO <br /> APPLICANT'S iIGNATi1RH�� <br /> DATE <p' <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 <br /> owner, the arty must ac nowledge this responsibility for the,billing by sig at e' anddatebe ow prosy <br /> Us P, t�,leu rn �r <br /> Namel���N'. �rt�l�, �� '' <br /> �t 14Z Address rk 1 A-9/6:�Q Phone# <br /> Signatur A v <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />