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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 /> 1 I EPA SITE # I PROJECT CONTACT & TELEPHONE # <br /> i <br /> I <br /> 1 F { FACILITY NAME I PHONE # <br /> / _ ------------ = - E------1 <br /> C I ADDRESS -- CA- <br /> ---'-- <br /> 1 <br /> I L { CROSS STREET__ a��_ -----` <br /> ' T { OWNER/OPERATOR { PHONE # 1 <br /> I Y { �,r I � � i <br /> {---+----------------- - - -- -- - ----------------------------------------+----------------------------------------i <br /> { C { CONTRACTOR NAME I PHONE # <br /> 0 +-------------------- '- --�1� -=--------- ---- i <br /> -------------- ------------------------------� <br /> { N I CONTRACTOR ADDRESS I CA LIC # { CLASS { <br /> IT +-----------------------------------------------------------------------------------------------------------------------------f <br /> { R I INSURER ---` WORK_COMP.# { <br /> ----------------------------------------------------- <br /> ---- <br /> { C I OTHER INFORMATION { { <br /> Oi----------------------------------------------'-------------------------------------= PHONE-#--------------------------------` <br /> R -------------------------------------------------------------------------------------+----------------------------------------� <br /> I I I PHONE-# <br /> +---fillllllll{lilllllllll{II{illl{I------------------------------------------------------------ --------------------------------- <br /> i <br /> I { TANK ID # I TANK SIZE { CHEMICALS STORED CURRENTLY/PREVIOUSLY { DATE UST INSTALLED <br /> 1 I 39 1 I I <br /> I i <br /> A 139- <br /> N 1 39- i <br /> 1 <br /> 1 K I 39- <br /> I { 39- i { <br /> -p39- <br /> -illllllllil{lil {� III Ili{II fl{il{ii{li ill�SEE <br /> I II 111 :{{i1{{L I APPROVED APPROVED WITH CONDITIONS) DISAPPROVEDA { ATTACHMENT WITH CONDITIONS) { <br /> N { PLAN REVIEWERS NAME <br /> +---illlllllll{III1111111{11111 Ilil{il{fili:ll{il{illii{i Ifli�ll�{lili I if{II{il:: i II {I111{ill it ..I I IIII I Ifif�iiii` <br /> I <br /> 1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, 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 1 <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 1 <br /> { BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> { <br /> { FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO 1 <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA.* i <br /> { <br /> i APPLICANT'S SIGNATURE: TITLE L</ f' DATE 1 <br /> { <br /> +----------------------------------- ------------------------------- <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 /> NamegIrIg Address.-/.- L/ I I , SJ--,­-T­,"�­, smPhone# <br /> Signature <br /> d <br /> EH230038 <br /> (revised 1/31/02) <br />