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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 )�PfWNFrREPAIR/RETROFIT ____UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />---------------------------------------------------------------------- c---�-"q-------------------------------- <br />EPA SITE # PROJECT CONTACT & TELEPHONE-- - �-/! <br />F I FACILITY NAME ------ PHONE <br />- - -------------------------- -----%��'-------i <br />C 1 ADDRESS ) '� 1 <br />1 I +--------------- / 5�/�/-�� /�� �C�= f- L�i✓l� - - -- - ------ -- -i <br />1 L 1 CROSS STREET �( j� �l j /J jl /1 �\ 1 <br />T I OWNER/OPERATOR C{��{'� «c,i/-`J C� 1 PHONE # 1 <br />1-Y-:-------------iC_-,ZG sv--- -{�� �rX =------------ ? <br />�,^� `---------------------- ,1 / �j - <br />1 C 1 CONTRACTOR NAME -�.}�{�, S*W 1b jZ C vA S�rv&�1 h _ 1 PHONE # �S 3 V� I 2 2 ---------------------- <br />N <br />_ I -112,1 _ <br />1 N 1 CONTRACTOR ADDRESS 440 <br />1 t.S4 (,I-. Pk1NaV� CA 1 CA LIC # /SS $ ( j I CLASS A 04 <br />1 ___________________________- <br />----/----------------'----^------ <br />1 R 1 INSURERVL �n L. ,I. 4-4 Q n r. t t 1 WORK. COMP. # f1 <br />-------------------------------------- <br />1 C 1 OTHER INFORMATION <br />1 T{____________________________________________________________________________________{____ __________________________1 <br />0 1 1 PHONE # 1 <br />1________________________________________________________________________ 1 <br />PHONE # 1 <br />{___III11111111111111111111111111111______________________________________________________________________________________________ <br />I <br />II111111111111111111111111111111 I <br />TANK ID # 1 TANK SIZE 1 C ICALS STORED CURRENTLY/PREVIOUSLY i DATE UST INSTALLED <br />_ 1 <br />39- <br />T i 39- i ib�f C)60 <br />A 39- <br />N i 39- <br />1 K i 39- <br />39- <br />39- <br />111 1 1 1 1 1 1 1 1 1 1 t I <br />9- <br />39-39'1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 <br />P i <br />1 L 1 APPROVED APPROVED WITH CONDITION(S* _ DISAPPROVED 1 <br />1 N 1 PLAN REVIEWERS NAME —ISE ATTACHMENT WITH CONDITIONS) DAA Q <br />c U <br />--MIM! <br />II II:11m,1:1 <br />11 m 1111111111111111111111111111111111111111111111111111111111111111 m ,II 11111111 11111111111111111111111111 <br />111111111111111111111111111111111111111111I111111111111111111111111 11111111111111111111111111111111111111111111111111111111111 <br />1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF 1 <br />1 SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 1 <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO I <br />1 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE 1 <br />1 FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO 1 <br />COMPENSATION LAWS OF CALIFORNIA." 1 <br />1 <br />! APPLICANT'S SIGNATURE: V TITLE �� lel /(.�` DATE <br />I <br />{_________________________________________________________________________________________________________________________________{ <br />BILLING INFORMATION: <br />THAT IN THE <br />WORKER'S <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 />Name --Address <br />ON <br />Phone # <br />