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11 <br />SAN JOAQUIN COUNTY <br />• <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 />IN ANY SHADED AREAS. INDICATE <br />THIS PERMIT <br />PZ OFIT �PIPING E REPAIR/RETROFIT NO —UNDERWRITE <br />SPENSER CONTAINMENT REPAIR/RETRIOFITPE BELOW: <br />+------------------------II----------------------------------------------------------`------------------------------------------------+ <br />EPA SITE # ---------_-PROJECT CONTACT & TELEPHONE #--__ f j1 � �1/- - li% <br />F ; FACILITY NAME ,,��,�11�� PHONE # <br />A +------------- --- ----- -------------- i------------- <br />----------------------------------------- <br />C ADDRESS <br />j■/ 1---/-------!-/-���1-----------i�-�ciGe'-j--C.�--------------------------' <br />I +-------- !------ - <br />L CROSS STREET <br />I+----------------------------------------------------------------------------------------------------------------------------- <br />, <br />T OWNER/OPERATOR PHONE # <br />Y <br />-------------- ------------------------------------------------- <br />C -------rte J�?---Y_---------+----------�--lr1 �1�__ <br />- -------------------- <br />C CONTRACTOR NAME PHONE # I' <br />----��u <br />N 1 CONTRACTORADDRES------S� �J r_��/��_/ -I�/� - ------------------------------------------------- <br />Z-.e <br />-A LIC # -�-_- -__-y_1- <br />Or <br />T + <br />A INSURER ��!)--y�/ +J-- + <br />C OTHER INFORMATION ' ! SLI'/_/ <br />, <br />T+----------------- ---------------------- ---------------+----------------------------------- <br />0 PHONE # <br />PHONE # <br />39- TANK ID TANK SIZE <br />CHF�7jj Ay^D CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED <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 <br />A�� _ CHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME WC�� DATE O <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 />01 <br />APPLICANT'S SIGNATURE: TITLE DATE <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 />Nam�,�i�' ;r;'jvvj A1jyj ddressjZ;WQ �j&j Z g4f-ZPhone <br />g ����1�i��0 ��l�f✓1�� G,1�. <br />Si nature�2 <br />EH230038 <br />(revised 1/31/02) <br />1 <br />