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. • <br /> 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 /> ----------------------------------------------------------------------------- -ppp-----------(___ + <br /> i_--i EPA SITE # 1 PROJECT CONTACT-&-TELEPHONE #-- ,[.�.Ty' �( - I,-Y-- qt � G(34 r� -1 <br /> 11 ' 1 ✓ __________\\---____ _ <br /> I +___________________________________________________________ _____ <br /> I F 1 FACILITY NAME ///n��1/ /�/� /�/[/✓// 5- y//Q I PHONE # <br /> C I ADDRESS �(Q_�__ t-- ��` ______________________________________ <br /> cull <br /> I ------------------ 111 "`===-n ------�----- , ------------------------------------------------ <br /> 1, <br /> -- - <br /> L 1 CROSS STREET 1��] L�/ �/t ' <br /> I +_______________________ __________________________________________________________________________________________________I <br /> 1 T I OWNER/OPERATOR � PHONE # <br /> / I <br /> ----�r '� <br /> 1 C I CONTRACTOR NAMEI PHONE # <br /> I ______________ ________________________________________I <br /> N I CONTRACTOR ADDRESS 1 CA LIC # 1 CLASS <br /> T +---S ------------- <br /> _____________________I <br /> 1 ER WORK.COMP.# <br /> 1 R I INSURER <br /> I C 1 OTHER INFORMATION I <br /> 1 T +____________________________________________________________________________________+________________________________________i <br /> 1 0 1 1 PHONE # <br /> ___________________+____-___________________________________I <br /> I 1 I PHONE # 1 <br /> 1111 I III 1 1111 II IIIIIIIII I------------------------------SSSS-`-----`-------'------------------------------------SSSS-i <br /> +---11111111111111 111111111111111111 <br /> I 1 TANK ID # I � �SIZE 1 CHEMI �YO� T TSTA <br /> CURREWLY/PRE LOUSLY DATE U LLED 1 <br /> I i <br /> 39-_ i CW I L�-- / <br /> I T 1 39- ©�d 1 i N <br /> I p 1 39- 1 n f7 fX1 I J )1 <br /> I I I <br /> 1 N 1 39- 1 <br /> K 1 39- <br /> 1 I I <br /> 1 <br /> 39- <br /> 39-_ <br /> 9 39- <br /> iiiiiiii liiiiiiliiiiiiliill <br /> 1 P <br /> J L I APP OVED APPRO WITH CONDITIONS DISAPPROVED <br /> 1 p 1 SEE ATA WITH C ITIONS) <br /> I N 1 PLAN REVIEWERS NAME DATE lll/// <br /> +---III11111111H I M Jill 111111111111111111111 IIIltll111111 I111111111111111111111111111111111111111111111111111111111111111111111 <br /> 1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE.LAWS, AND RULES AND REGULATIONS OF 1 <br /> 1 SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY I 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 /> 1 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE 1 <br /> 1 FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO 1 1 WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." 1 <br /> I <br /> 1 ' <br /> I <br /> I <br /> 1 - C <br /> APPLICANT'S SIGNATURE: TITLE TE . <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 owner, <br /> the party must acknowledge this responsibility for the billing Asiature anddate below. <br /> Name- � dres (��� 1 ______Phone#a- <br /> ff F <br />