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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 />+------------------------------------------------------------------------------------------------------------------------+ <br />EPA SITE # �/n _ u PROJECT CONTACT & THLHPHONS #__ A�.a� / -dope) - -4 Azo .�'X-------- <br />---------------- <br />, <br />+-------------- Q� K Q-- 0----------------------------------------------- J ! <br />F FACILITY NAME <br />--- � -rc o----- 3---------------------------------------------PHONE-#-A +-----------------t1�-- <br />----- <br />I <br />C ; ADDRESS 0� N`C�wI +-------------- ----------------------------------------- <br />L ; CROSS STREET �- <br />CL - <br />T OWNER/OPERATOR l�'r�d /� ^ PHONE # �16 6�' /�O0 <br />, Y �./ <br />I---+-------------------/------------------------------------------------------------- ---------------------/-------------- <br />C I CONTRACTOR NAME_-('G*�I�r--�f-q---------------------------------------------- HONE----��__'13�_-_7/��----, <br />�2a PHONE # <br />o +----------------- S,.:t< 1 � 793 .14 - - - - - , <br />N CONTRACTOR ADDRESS '3lt4O� \--CgMp--11�_�.----------------------------------------------------------- <br />R <br />-----------P-LIC-#---------------------CLASS <br />Vr - - -------------------- <br />R INSURER I WORK.COMP.# <br />, <br />�� <br />A------------------------------------------------------------------------------------+----------------------------------------I <br />G12c.Joronjer �_ 0 113 <br />C OTHER INFORMATION <br />T+-----------------------------__ ll ---------+----------------------------------------' <br />O ,(//� / /` �^ Q I PHONE # -----------------------I <br />R +----L-3-1_�C,!'10---- l -O J'�O'� ---- 1. �'�. 7S �C7 +----------------- <br />PHONE # <br />1391111111,T�AIK ID # ��TFLN�\SIZE <br />(� IHMICALS STORED CURRENTLY/PRSVIOVSLY DAT$ UST I�rSTALLED <br />6 [ w2 tin a ►J <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39- <br />P <br />L APPROVED _ APPROVED WITH CONDITION(S) DISAPPROVED / //o? <br />A (5HB TA. T�CHMHNT WITH CONDITIONS) DATE ` L " 6 <br />N PLAN REVIEWERS NAME %0/��eL/��"+<� <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-k-Nt .� DATE III' -U <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 />Name <br />Signature, <br />EH230038 <br />(revised 1/31/02) <br />Address <br />1 <br />Phone # <br />