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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 <br /> '- ---- CC rr <br /> nd <br /> EPA SITfi __ I� JECT CONTA('C_6-TELEPHONE_*_ -_� PHO r&- �J59�8s$� 4'l b-_+ <br /> ---mss-- -- l --HONE-- - ---------U----V---I ---- <br /> -------------- - <br /> -- <br /> F FACILITY NAME <br /> A ________________ 7 <br /> I +-ADDRESS--��I_---J:-1"- - -}-Ierr�Cih__l, n��--�„� - ---------�_5a <br /> C <br /> ,/� - ------------- ------------------ <br /> L CROSS STREET S. �� jJ . <br /> ---------------------------- <br /> T OWNER/OPERATO PHO <br /> M <br /> Y u s iq Ne r � a4 j r) o5 a J�-4' ado <br /> -------------------------------------- -- -----------------------------` 8 <br /> -- -- ----- <br /> C ; CONTRACTOR NAME __ _ _ __ __ _________ <br /> O .---------------- � _-I��-j--�-----e-- ---------r�,�C.2S--- I PHONE---- q Y /�`7�_ !O � (� I 00 <br /> -- - - - - -- <br /> T --------------------CONTRACTOR ADDRESS___ •__ _ C _�___.______ni�T_-__._______CA LIC tf 7--------------------------------- <br /> y'�p�______CLASS J� �fa-Z (�(dT 1'1 b�(i�� <br /> Q�-------1 ;�� i+ n C-, L QJ 7 <br /> AR INSURER-C I.. (C �a_______________________ _�---__-_- <br /> ----------------+_WORK.COMP- --/------- <br /> C OTHER INFORMATION <br /> T ----------------------------------------------------------- t <br /> O ' ; PHONE # <br /> Rt______________________________________ <br /> PHONE # <br /> ____________________ _-_____-_-___________-___-_- _____________-_______________---_ <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> A <br /> 9-A 39'N 39- --- ---_ _ <br /> • <br /> K 39- <br /> --- ___ <br /> P l <br /> _ APPROVED _APPROVED WITH CONDITIONS) DISAPPROVED <br /> A (SEE.ATTACHMENT WITH CONDITIONS <br /> N 1 PLAN REVIEWERS NAME DATE 1 <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 /> U- <br /> APPLICANT'S SIGNATURE: TITLE / �V� DATE <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 res�nsibility for the billing by signature and date below. <br /> ��1h ��,Ot-t, o5 RQnch� n ''�i�lJd. 1 <br /> Namel�5 �Q���; M2�;cP. Address�L;z �err7rk/ C�4 4� Phone# C�c�SJ �I`F-�a� <br /> Signature- ( s <br /> EH230038 <br /> (revised 1/31/02) <br />