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.USAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT . <br /> 304 E WEBER AVE,3PD FLOOR. <br /> STOC KTON.CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT.EXPIRE$90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> _TANK RETROFIT PIPING REpAIRlRETROFIT,^UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> *--------- -- -- ------------------------------- ----------------------- --- --------------------------- --------------------+ <br /> 1 -SPA 6YTZ # i PROJECT CQNTACT & TELEPHQNE # _ <br /> I F + PACILITY.NAME `V:[C�.+V V�`----....-.----'-----___.,------------------------------------- <br /> -i <br /> :------- .....�----- ---------- - --- -- -_ ------ <br /> .0 1 AD--- `3_d.L. --"" -i--�Ld.LY:`� -.«..} _� <br /> ;. L ; CROSS STREET <br /> .. <br /> . 176..E <br /> 1 <br /> -�-1-1`_n------•- ----------------------------------------- .......... - <br /> T I OWMMIOPERATOR PHONE # oZGqC 1 <br /> 1 C COUTRACTOR�NAM& ----- 2•^--- ----__-.....- -- -."___ PHOHS fk pU,3• ; <br /> D +-- ------=------ -Sc�-�th�.i-J -( U't S ---------------- `,/t-- ----- e(�3^�. . <br /> a ------------------------coxxRhCTOR ADDRESS /1 /:y q�n�� Lj_ iA _` er��srpsi ,_901A- .I CA LSC-M_l.�Q��,9^-------1 CpL�A56e/B�jJ�Qf./I�D��11AZIfIG <br /> Ai-;NEVRSR Cu sS�i `iAgTlPjy"1�34�40_l� .i_SS1Sv�1�L Xz ....... .......+-------------!�1TDJ�iQ_ <br /> C i OTHER INFORMATION <br /> ' T •"------------------------------------------------------- ----".....m-_-------- r <br /> O I I PHONE 4 , <br /> iR ro..-------------------- ------------------------------------------------ <br /> PRONE # <br /> -----------•—:--------------------..-------------------------------------------------—.......---{ <br /> TANG In # I VANX SIZE =MICALS STORE4 CURPMTLYJPREVIOQELY 1 DATE QST INSTALLED { <br /> T -- <br /> A 39- i <br /> . N 139- <br /> K 39- <br /> 1 39-_ i <br /> 1 A i <br /> I L 1 AF7iR APPR 9PITH coanYx2 SSI DI:.APPROVED 1 <br /> i.A { Ssaa ATTA NT WZTH CONDITION 0--17— <br /> I <br /> "'PiI N PLAN PEVIE9esk5.N$ME DATE <br /> ----r{i{iii iii{ {{i.r+.i{i,,.ri{,r {1 '� i �." " '� ...., riiiii{,r { i �i i{{" rr ".r.."• „ii, <br /> , i i1. ...i.... . , r,.i „ri iii„-i,riil{, i„. r•{ii, riii I{1. ii i „ii� 1i,..., .,,iirririiii; <br /> I <br /> APPLICANT MUST PERFORM ALL KORA IN ACCORDANCE imn $AN ,70Aoum COQNTY ORDINANCES, 6TATE LAWS, AND RULES AND REGOLATZCNs OF <br /> SAN JOAQUZN MeaTY, ENVIRONMENTAL HFW,TH DEPARTMENT. OWNER OR LIcws= AGENT'S SIGNATURE csATirfEs THE FOLLOWING: •I CERTIFY <br /> THXT IN THE RZRFORMANCE OF THE WORK FOR WRICH THIS PERMIT SS ISSUED, I'SHALL NOT EMPLOY ANY PERSCN IN SUCH A MANNER A:To I <br /> BECOME SUBJECT TO WORKER'. COMPENSATION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR GUBCONTRACTINO SIGNATURE CXx=PIES TIE <br /> FOLLOWING.- "I CERTIFY THAT ZN THE PERFORMANOE OF TBS WORK FOR WHICH THIS PERMIT iE 26.GED, I SHALL EMPLOY PERSONS SUBJECT TO I <br /> i WORIM'S COMPENSATXQN LANE OF CALIFORNIA." i <br /> { <br /> j. 1nnTTn1nm1'n nrr=111121 MV ?fii I <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 /> 4S'1t� <br /> NameSZ+�i-e -+16M-U3{ W. ddress 06 aViy.0 �c��,S Phone# $-'a13-!p03$� <br /> Signature <br /> EH230038 <br /> (revised 1J31/02) <br />