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11! VY/ Z.UUY CI J. JL <br />4Uj4001') 00 <br />r l r i n r L.uum <br />• • <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE. 3'0 FLOOR <br />STOCKTON. CA 95202 <br />rWt= ria <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE, 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMrr TYPE BELOW: <br />_TANK RETROFIT PIPING REPAIRIRETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />-------- ------------------- <br />i SPA SITE $----...__! PROJECT CONTACT s TZLHP11 a KA�N�1�I t-_--5 -- LLt 11IA .---------� <br />-------------- '_----------------- _ <br />I P FACILITY_NAME SR �� x.14..- - / 9 <br />1 <br />kl---------�4 1------------- - ----�+'� ---- -- .... - - <br />A�..-------------------------_------------ <br />I <br />- ----------� <br />C ( AnD[tESS �%� t2� <br />L 1 CROSS-- STREET - - �"�--- Dk _....-- ----- -- --I <br />T + OWNER/OPERATOR <br />------ - / !-Flout -# V �- <br />Y ,E � N c.,---- - L1�1_C��.-N------------------------- ------ . <br />i---+---------------- - RHONE # <br />l0+----•-----------• - - I Z �- t CLASS 1 <br />N CONTRACTOR ADDNt8S9 G LIC x <br />__ - - <br />a.-�.._ j--------------- pZ Q_ <br />R INSURN -------- +----------------"----------- ------- <br />C I OTHgR INFORMATION _---.I ----..•,-----------••••_-- -i <br />-------------- ---....------ •---_ ...---- <br />I T a----------------- � PHONNB A <br />101 <br />---11111111{11111111111illlll111111------------------------------- --------------------- --------••---------•'-------------•------- <br />'romy Tn a ! _ TANK SIZE I CREMICALS STORM CURRENTLY/PUVIOUSLY DATE UST INSTALLED <br />I t <br />lT1 <br />'AI.N <br />1R� <br />1LL <br />A <br />NI <br />39--� — <br />39- <br />30- <br />39- <br />39- <br />39- <br />Ilil 111111111 t, Illlllli 1, <br />APPROVED WITH CONDITIONN(S'S%_ <br />ATTACHMENT WITH CONDITIONS) <br />PLAN REVZ WEBS NAME <br />11111,111111111111111 <br />I <br />I <br />I i <br />1,. „ 111111 .I. 1!!11111 ...II liil <br />DISAPPROVED 1 <br />DATE 1 <br />11mi ii1111I1,, illi) 1 ,111, 1111111,771 <br />1 STATE LAN$, AND RULSS AND REGULATIONS OF <br />1 APPLICANT Musr PER70RM ALL WORK IN ACCORDANCE WITH <br />SAN JOAQUIN COUNTY ORDIDIANCES, <br />SAN JOAQNTN COUNTY. EMVIRONMENTAL $EALTH DEPARTMENT. OWNER OR LZC'.8lSRD AGMIT'S SIGNATURE CERTLPIES THE POLUMING: "I CERTIFY i <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO 1 <br />l SEOOME SUSJSCT TO WORKER'$ COMPENSATION LAWS OF CALIFORNIA." CONTRAC'TOR'S HIRING OR M-SCONITRACTIVO SIGNATURS CERTIFIES TRZ <br />j FOLLOWING: -I CERTIFY TKAT IN TINE PERFORMANCE OF THE WORK <br />FOR WHICN9 TNNIS PERMIT IS ISSUED. I SHALL EMPLOY PEkSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF TALI SIA•" l <br />ATE <br />ATr <br />APPLICANT'S SIGNATURE: TITLE <br />I------------------------------------------:---.._- <br />BILLING INFORMATION: Z -fie d`+�cri►h{n�r�HS Sd►BtrC- M'o <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 />Z <br />Signature. <br />EH230038 <br />(revised 1/31/02) <br />ress <br />�Phone# CA <br />1 <br />