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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 />ZANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />--------------------------------------------------------------------------------------------------------------r-�-c-�----------- <br />EPA SITE # C.HVO-�OO Z\C��_-_-_-__-PROJJE�nCT CONTACT 6�TELEPHONE <br />C#1,R1L.�bl\'1C1, E.-_/��_____�1^_(I�_I_•- ��(�---__. <br />F FACILITY NAME <br />'eViT--k_Y�-`r <br />PHONE_ #�.._`tJ_J L I�._ _ <br />C ADDRESS " (0 0 <br />--- <br />L CROSS STREET (� <br />I----------------- QC L__jl�.-!4oi--------------------------------------------- ----------- ---- - <br />T OWNER/OPERATORPHONE # <br />Y <br />C CONTRACTOR NAME-11,�. r1+ ._PHONE # ..�?.�A�_��1_�Q. <br />v l <br />N CONTRACTOR ADDRESS- Q -(y' -'(i .moi t y (� j _ _ _��1�`.�.. f _�•i - - _ J.�,{�..LJ_�_ _ _ CA LIC- q-'7 �, h - - _ _ - - -CLASS <br />A _INSURER_._J!`__�Y.1�_=]7_`_2•___/_______________________________________♦_WORK. COMP.# �iy <br />C OTHER INFORMATION tel_ l-S1LL <br />T-------------------------------------------------------------------------------`--------__----- <br />O PHONE # <br />R----------------------------------- ....-------------------------------------------- _____,__�________..-.___-__-__._ <br />PHONE # <br />T 3 � TANK.ID #--------------I---------------------------------------------- - <br />TANK SIZE CHEMICALS STOREp CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- -iA�D,� _ '_ L/�+CPP -- — --L\'`�I -- --- 6 ---------- <br />9 —TrLI C -t 1C— -- 1f1, OGb ti. �. <br />A 3 9 - T/� Q .Z O �C'3 f� r nom-=---_-1�C IAn ----- CL( --------- <br />N 3 9 - ---- -----_ <br />K 1 39- <br />39- <br />.-P_, <br />L APPROVED APPROVED WITH CONDITIO DISAPPROVED <br />A ATT H CONDITION <br />N PLAN REVIEWERS NAME <br />DATE <br />- - _ <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 1N SUCH A MANNER AS T:; <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 T' <br />WORKER'S COMPENSATION LAWS OF CALIF'V `-'OI\(xR'�NI A." „ l <br />APPLICANT'S SIGNATURE: L) TITLE Qr �t,�+1 DATE <br />BILLING INFORMATION: <br />Indicate the responsible party to be gilled 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 />NameAddress�_Q ' �� IU I _ra��it �;,�_Phone #`' ( 0 <br />Signature <br />EH230038 <br />(revised 1/31/02) <br />