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UO/ UO/ LUUz U�. z)t 4b4U1J0 tNV INUNNILN I HL HLAL I H 1-Aizit Ul <br /> SAN JOAQU1N COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E wSSER AVE,3R0 FLOOR <br /> STOCKfON,CA 95202 <br /> APPLICATION FOR UNOERGROUNO 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 REPAnRETROFIT_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> --i--_......^ - -- c^ 1 �j•�Q <br /> I EPA SITE # -----I PROJEC .CONTACT & TELVRONE #�R�,Q„1(nC);;�:1 --5%01 <br /> '-..,,.,__________-_��_-_- _---`____________________________.._________-- <br /> F I FACILITY NAMfiPHONE A <br /> I A -------------------------- <br /> C -------._...--------------_.__.----- ._ <br /> IADDRESS � <br /> r ��_. ` Sao -� ... -------------------- <br /> _ `---- __ ? -------_ <br /> L � <br /> I CROSS STREET <br /> { I •-----------------w�....5^----------------------------------^------------------ ---------------------------------------I <br /> T L OWNER/OPERATOR I PHONE # I <br /> -------r -----^- ------------•._----------•--------------I PHONE # <br /> ' C^1 CONTRACTOR NAMSIAQ.WOY�yStO ��,( I�. -----•--'-------------�,0��1 -8380-------- <br /> 1 o r----�-- ---------- ---•_ .---- ...----- -- - (� p <br /> I N I CONTRACTOR ADDRESS DQ I CA LIC # �Q�� 1 CC1- I & <br /> { T +--------------------Z=�'----... .� �X45.. -----...--------- -. -- -- ;-----l---- - - <br /> -CLASS <br /> RI INMI;R ` Y`� _ -------------^------- r-•--------+-----......- ----------------- -- I <br /> ------- -- I I <br /> 1 C I OTHER INFORMATION <br /> I T ,__.....--------- -----------------------------------------------------------+---.------------------------------------I <br /> ------- - I PHONE # I <br /> O <br /> PHO" # I <br /> --------------- -------• <br /> +---illlllilllllllllllllllllllllllll-------------------------------------------------------- <br /> -------^ --•---I <br /> TANK ID # I TANK SIZE I CHEM <br /> I 1ODC1 ..-o. REVIOUSLY DATE UST INSTALLED <br /> 39- IVY == I <br /> I <br /> I T 1 39• <br /> L A I{ 39-N I 39_ <br /> 1 I <br /> K 1 39 <br /> f 139- 1 <br /> + 39- <br /> •- <br /> -tllll 111111 ILII 111111117FTM 1111111 II {IIIII I {1 11111 I{111111 I 111111111111 I' <br /> IP <br /> I L I ppPR ED PPROYED TH CONDITION(S) _ DISAPPROVED I <br /> ( A TH CONUITiONS) <br /> i <br /> I A DATE Z-- <br /> N I PLAN REVIEWERS NAME <br /> • --lllllllllllllllllllfllll II II II I I III III{III III III111111Fill Illllillll I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. STATE TAWS, AND RVLI+9 AND REGULATIONS OF 1 <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIMATURE CERTIFIES THE POLLOWINGa •I CERTIFY <br /> ( THAT IN THE PERFORMANCE OF THE WORK POR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO 1 <br /> BECOME SUBJzCT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I <br /> FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERS0144 SUBJECT TO <br /> WORKER'S COMPpXSATION LAWS OV CALIFORNIA." I <br /> r <br /> � <br /> TITLEI�`1N• r �Ii�DATE �2" I <br /> I APPLICANT'S SIGNATURE: <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 <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> S Phone # S <br /> Name� a14o (\o • ,�tu4 Address Z fOo %10'4 to b t`Q'83� <br /> ASI <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br />