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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 EPA SITE # ____'_PROJECT CONTACT & TELEPHONE # r <br /> ---------------------------------------- ---------------------------- � �__ 11 4 aha ------------- <br /> F 1 FACILITY NAME A k �` I PHONE # <br /> f� IY <br /> A +--------------------------------- <br /> 1 C I ADDRESS J-i Ali--- b- , �- `,� <br /> I = + ZATHn.�P------------------ <br /> 1 L I CROSS STREET - g- <br /> i <br /> T 1 OWNER/OPERATOR I PHONE # I <br /> Y ( ,A ua Tc i LL 1 � �_1V_ �V <br /> 1 C 1 CONTRACTOR NAMEf v n I PHONE # f -r1 y - lam y <br /> IO --------------------------------------A ----I------------------------------------------------ ----- ------------------------1 <br /> N 1 CONTRACTOR ADDRESS Q� . f 4 -r ` k" CA LIC # ----- <br /> I c-LAW--- ' <br /> R 1 INSURER \ <br /> 1 _ A-- F 1 WORK.COMP.# a� <br /> ��, 1 WORK.COMP.# <br /> __________ _________________ ---------- <br /> C <br /> I <br /> OTHER INFORMATION I I <br /> 0 1 1 PHONE # 1 <br /> R +____________________________________________________________________________________ <br /> I PHONE # <br /> + illlllillilillliilllllllilllllll-------------------------------------------------------------------------------------------I <br /> TANK ID # I TANK SIZE 1 CHEMICALS STORED CURRENTLY/PREVIOUSLY 1 DATE UST INSTALLED 1 <br /> 39- i I <br /> T 1 39- <br /> A <br /> 9 A i 39- I I <br /> I N 39- <br /> 1 <br /> 9-1 K 39- <br /> 39- <br /> 39- <br /> P <br /> 9-39-39-PI <br /> L 1 PPROVED _APPROVED WITH CONDITION(S) _DISAPPROVED I <br /> A i (SEE A WI TI�1 ,r <br /> 1 N I PLAN REVIEWERS NAME E� DATE v <br /> + IIII III1111111111177I illlll "I'll lllIIIIIIIIIIIllIIIIIIIIIIIiIIIIIII1111111iIIIIIiiIIIIH 11111lllllllillIIIIII IIIill III IIIll <br /> I I <br /> 1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF 1 <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICE24SED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 1 I THAT IN THE <br /> 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 1 <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I I WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> �0 n <br /> APPLICANT'S SIGNATURE: £/p' TITLE DATE IM TlJ!I <br /> I <br /> +------ ----- <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 owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name Address Phone# <br /> 1 <br />