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• � CYC nys3(oy <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3" 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 />+-------------------------------------------------------------------------------- <br />; EPA SITE# <br />PROJECT CONTACT & TELEPHONE # <br />-------- -- --(C H A E Lo9J6 -3 � 3- l+---------------------------------------------------------------------------- ------------------------- <br />F ; FACILITY NAME PHONE # <br />A +-----------------fi--LLA OtL 30r- <br />-S- z- <br />-- <br />---------------------------------------------------------- s ----- <br />; C; ADDRESS 3 3 o a (,(/ A TS QI L o 0 2 t- <br />I+----------------------------------------------------- --- -----------F S 2 O.r <br />L; CROSS STREET <br />I+----------------- -- C f' o R ---- A_v__E = --------------------------- <br />T OWNER/OPERATORPH ' <br />' ONE # <br />Y / (ELL A O(L C00%f>Amy, LC C - T30- $'rnr 0 <br />--------------------------------------------------------------------------------------------------------------------------------- <br />q0 j <br />C CONTRACTOR -NAME---`= CO----�.-'- -----PHONE-#- 9� G <br />O+----------- <br />G <br />N CONTRACTOR ADDRESS o7- r A.-, �' - y ' (pCj (--_-CA-LIC-#- 6 } 2. 3 Y -------CLASS- A 8 bi qZ <br />' T --------------------------------------------------------- <br />R INSURER.T.q, �'U�� ; WORK.COMP.# ��30oo•(gz�oS' <br />L <br />C OTHER INFORMATION <br />0 ! , PHONE # <br />R+------------------------------------------------------------------------------------+----------------------------------------' <br />PHONE # <br />---------------------------------------------------------------------------------------------- <br />TANK ID # TANK SIZE ; CHEMICALS STORED CURRENTLY PREVIOUSLY DATE UST INSTALLED <br />39- O ( z. 00 O <br />T 39- p 'L 14D. O• O S l <br />A 39- D3 /O, 000 <br />N 39- <br />K 39- <br />39- <br />39- <br />IIIIIIIII;II'I" " <br />P1 1 <br />L APPRO _PROVED WITH CONDITION (S) " _ IDISAPPROVED����������� 'll'I'III' <br />A (SEE AT ACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <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 />APPLICANT'S SIGNATURE:TITLE CQ MIT 7- A.,"tQ /'L DATE Z. Q� <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 />W Q L -T -b,4 p. p. B o x to? S- 9t h <br />Name ,ur- Address lel- S A�c�t-0, C4 qs6 a Phone# 3: 3 - I(r--..._ <br />Signature I <br />EH230038 �" `� �� U✓y <br />(revised 1/31/02) <br />1 <br />