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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE.3'0 FLOOR <br /> STU(:K TON.CA 95201 <br /> APPLICATION FOR UNL)ERGROUNU 1 ANK RETROF IT 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/RE TRUE;I - UNDER DISPENSER CONTAINMENT REPAIR(RETROFIT <br /> EPA SITE a <br /> C-A R Ib(.0 PR,I,IE­> 'r4J'I'A;7 <br /> F FACI:.ITY NAME <br /> A S� C.QJ PHONE 4 3 b <br /> - - Cam) �9=3 gay <br /> �.' ADORES:; Kai+le h-o n `^C`)a L-od- c.A- _5_�y_ _a ---- <br /> CROSS STREET(+VAC(� ' <br /> ' 'OWNERlOPERATOR - ------- - - - .- -----,----_--_-- <br /> Y - �CJR _ J QC I_f U Ie L4 ,._��rpru4--,�� PHONE-I! W� �►�-gaol! <br /> CONTRACTOR NAME --. - __ <br /> - orc r Corr;:Aruc-_4 i�n PHONE « C,q��}� (0 30-�,_�� --- <br /> N COKTRACIY)R ADDRESS - - --- ---__ _ <br /> SIS � �l len 44,4 .,�jnt►rnas .A 4 �g ��Ass _3 Hoz y►c <br /> R INSURER �`� <br /> A _- t�e Fund _ <br /> UTHiQ2 I NPORIMT!ON ---_---- 57 <br /> T <br /> (1 <br /> PHONE. 4 <br /> _ - _ -________._ <br /> ---- --- - _ PHONE 4 --- <br /> TANK yI,D <br /> 39 p©O a JI c.� �� IQ.I vo { K�vh 'h MI rA:.:: STORED CIIRREN7':.Y iPRF.VIOUS:.Y DATE UST INSTALL®__ <br /> A s9- -- - (�7 6 J GVH U /bf1 Qjc�(O r C l.rl 12AC1 QQJoL1Ale — <br /> N 39- <br /> 39- <br /> 39- <br /> F _- - <br /> A APPROVED APPvOVEI. <br /> N PLAN REVIEWERS NAME <br /> ISE): ATTACHMEN^.'�>v;Tf• :)I SAPP�')VFI, <br /> 'nN'U 1'TI ONS, <br /> :,ATF <br /> AP P:.IUANT N l' 1'E.'R FARM A:.:, MURK :N A('�'',)R1)ANr't: WITH SAN JOAO(Ilt. "JUNTY ORDINANCES. STATE.' :J illi AN[ RII:.E:, ANl) 2F.GI7..ATI <br /> .SAN JIN THE :'()RFOR. ENV IOFRC) THE <br /> HEA:,TF- UEPAHTNMNT UWlIHR UR .-ICENSED AGENT'S SIGNATURE '.'E KTIF'1 ES Tf{k: F1',...,Uy1NG <br /> THAT [N THE PERFORMANCE UNS .)F' <br /> OF THE MURK EVR WHICH THI:; PERMIT I:: ISSUED, I SHA:.:. NOT ENPWY ANY Y rERTIFY <br /> BECY)t'IE SUBJ"Ei TO WORXEH'S COMPENSATION' :.AMS OF CA:.IFORNIA." ,'O ERSON IN SUCH A MANNUR AS T,) <br /> ING: '! ,:'ERTIPY THAT IN THE PERFORMANCE UP WHICH <br /> THI R'S HIRING OR SUBCONTRACTING SIGNATURE 'CERTIFIES THE <br /> WORKER';: COMPENSATION .-AWS OF CA-1PURNIA �)' MURK PO.� WHICH THIS PERMI? 15 ISSUED, <br /> HA-.:. EMP:,U`YQ1 PERSONS SUBJECT TU <br /> APPL:CAl;T'S 51GNATU� <br /> r:r E C0� <br /> DATE ��a►___ <br /> BILLING INFORMATION- <br /> indicate the responsible party to be billed for additional EHD staff time e <br /> coverage per tank If the party designated below is different than the beyond permit payment <br /> owner, the permit applicant, e.g_ ply <br /> IISKI pa acknowledge this responsibility for the billing by signature and date below. <br /> Name-(t9A�,>. 1 LR, Address c��JrtCyw '`�o/�J�ct. <br /> �cbC c / J Phonec�5� a��a� 1��' <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />