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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3�D 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 _V_PIPING REPAIRIRETROFIT - __UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +- --------------- ----------------------- --------------------------------------------------------------+ <br /> I EPA SITE # -?T00 O .1.11 2 I PROJECT CONTACT S.TELEPHONE # 11 /n Cn(A e 1 I A4t,+'2014- 1 <br /> +_________________________________ _______--_______-_-________________ --___--_____-----_____-_______-______----___I <br /> F ; FACILITY NAME P�LI c_m111 i_'_m�+ y._6as______________I_PHONE #__ 4-73- 10-7- -- __________ <br /> A+_________________________ iI;- I� <br /> C ( ADDRESS <br /> L CROSS STREET <br /> I <br /> Ro�eyn ej ej------ ------- <br /> T OWNER/OPERATOR <br /> II <br /> helrI - 1I' <br /> PHONE <br /> E^# <br /> IY GI gvio- Cabrero, "-q---H73-SS-1-1-1yA <br /> -/ <br /> --+----------------------- - o__ _ - ---------------------------+---------------------------------------- <br /> C <br /> -------- ------ ------- <br /> �--- <br /> ---- <br /> C CONTRACTOR NAME V1�1v'vfW I PHONE # <br /> Or1ne ------- ----- ------------------------ y ------- ---- <br /> N CONTRACTOR ADDRESS LICAe'rl ---- -#--- <br /> R <br /> I <br /> INSURER WORK.COMP.# <br /> A I- ---------- Vic..Corn Sad►-olc�- -+end------------+---------------13'Oo--�F7 --I <br /> C I OTTLER INFORMATION I <br /> ---------------------------------------- <br /> 0 <br /> --------------------------O 1 ; PHONE # <br /> R +------- -+------ ---I <br /> I PHONE # I <br /> +- IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII ------- -I <br /> TANK ID # TANK SIZE I CHEMICALS STORED CORRENTLY�;EVIOUSLY I DATE UST INSTALLED <br /> 39- I 00 0 UNLeADJ 69SQL( I <br /> T 39- I I doLYAry P �" I <br /> A I 39- I_ I PMI UM N <br /> N ; 39- I: Zoo O n,e.SeL <br /> K I 39_ I I <br /> 139- I I I <br /> 139- I <br /> +---IIIIIIIIIlI1I11111111111111111111111111111111111111 IIIIIIIIIIIIIIIIIIIIIIIII III IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII <br /> IPI <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A ( CHMPNT WITH CONDITIONS) <br /> N I PLAN REVIEWERS NAME DATE I <br /> ___IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII I IIIIIIII IIIA IIIIIIII <br /> I I <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 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 ; <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 I I WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> I <br /> I I <br /> APPLICANT'S SIGNATURE: Lvvaz 'v TITLE �� DATE <br /> ? <br /> I C•w <br /> +------------------------ t �d__Lt�I[1���J�-dS------------------ ------------ -----------+ <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 /> �j52o7 <br /> Name 61 ; l.L- <br /> vSeo brea. Address�-�S� ( �a.G 'L ���S�'-- Phone#_ <br /> __ y� 1LI]___ <br />