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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 � stULs �rg14c�"Lr <br /> +--------------------- ---------------------------------------- ---------------�A-+----��-11-�--'---------------------------------------+ <br /> ' ) EPA SITE # , PROJECT CONTACT & TELEPHONE # � C-------- <br /> F <br /> �- t tjkkLw-cLo <br /> _ -1 <br /> ' F ; FACILITY NAME ; PHONE # �`'1 <br /> l^ SY <br /> C ADDRESS R-04U%A-.e V- <br /> ' ,N,� <br /> L I CROSS STREET -- ---------------------------- <br /> ------------------ <br /> I +------------ --- by <br /> T <br /> ' OWNER/OPERATOR PHONE # <br /> ------------ aloz <br /> T---�'�� --- -----------I <br /> C I CONTRACTOR NAME �` PHONE # 4 6 ` � <br /> �--" -/-�-------`''!- 1{� s-' -----------------------------------;------------------ - ------ <br /> ' N 1 CONTRACTOR ADDRESS I 131�%l�� t7 '� ��'� , CA LIC # 8��� , CLASS a�ebi bito <br /> I{{pp f� Q� i <br /> T +---------------------- _jb--------,-----------r _f__k _----,J------------------------ ---------------- j ----------- -) <br /> i R ' INSURER l.((�' -�_C�. �'l��U� , WORK.COMP.# I- �P ---- - , <br /> --- - ----+----------------------------------------, <br /> C ; OTHER INFORMATION ' <br /> IT +------------------------------------------------------------------------------------+------------------------------------ <br /> I 0 I I PHONE_# <br /> , <br /> IR +------------------------------------------------------------------------------------+-PHONE #--------------------------------' <br /> TANK ID S# TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED <br /> 39- _ <br /> ! T ; 39- <br /> A 1 39- <br /> N I 39- <br /> K 39- <br /> 39- <br /> 39- <br /> I L I AP OVED PPROVED WITH CONDITION(S) DISAPPROV1] <br /> I p I ( EE TT CHMENT WITH CONDITIONS) <br /> I N ;PLAN REVIEWERS NAME DATE 110 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S -SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <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 <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,*I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: '{.��r-+-.I-LUQ+'�Vn'�t-'�-Y ,�r.�..�'(/`�' TITLE �61+y`'{�(.�au-� 6\\1YDATE � <br /> I -------------------- - C�- i - ---------------------------------------+ <br /> BILLING INFORMATION: AA,.-wkaq z '1-t -' ( -t 'Lt <br /> V(L Ltollk- <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 /> Nameft �, �n�� Wks -+6-W"Address �Cc'�����1,/1 �°�Sct�� e,'eA q hone# qOl -W3-&C5 <br /> Signature jtj t L :;t1 x 1 - "� .�-+ � 4.1,C <br /> En <br /> ta <br /> EH230038 �{$ {1.oa�t/L � -�-i/Kp ~' C"Y ,V_ f ad � 3 C� <br /> (revised 1/31/02) 2) '` "�'`� 44, <br /> �,� <br />