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Sep - 26. 2005 4:29PM W °ht Environmental 832-5152 No - 1320 P . 4/6 <br /> SAN JOAUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E W EBER AVE,3"O 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 1N ANY SHADED AREAS,INDICATE PERMIT TYPE BELOW; <br /> TANK RETROFIT PIPING REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT <br /> ----- <br /> I 1 EFA SITE N - I PROJECT CONTACT TELEPHONE #�[ !,S' r� , 7 <br /> ---- ---------------------- ------------ <br /> 1 ,p /� nn ) rry�e �) r�"� <br /> 1 I FACILITY N ------------------------- <br /> AME C �i_rV_. ry�._`_ �-' I PHONE # �J� �c�7 pCaOC <br /> 1 A ----------------- <br /> -- ---- <br /> I C I 1/� j� <br /> 1 I +aADDRES9...J.Tw! � L— ---L--------------___---------------------------I---------------------------- -I <br /> L 1 CROSS STREET <br /> -- 1 - <br /> ------- -.- -- ------- ........---------------------------------------------------------------------- --. <br /> PHONE # <br /> `` Y I OWNER/aPSRATGR( mmo e- I o711�—���- <br /> f � - ------------- --- - - I <br /> +----------------- -�-r +----.., I <br /> ----- ------ - <br /> C. I CONTRACTOR NAME f J �a {��rr '/n.A^ ,,(�, �p�.( "~ l PHONE # <br /> 0 +----------- -- 11` L_1v_L_Cd/� /�i_/(C_S� t*C_E,�.., =----------------- <br /> { N I CONTRACTOR ADDRESS '7 ,� r -C�I/ / I CA LTC # (�7�! / 1 CLASS <br /> T +- d -------------- -'4 -------------------------------------I <br /> R, i INSURER /}�- 1 .WORK.COMP.# { <br /> A1 --+----------------------------------------1 <br /> C 1 OTHER INFORMATION I 1 <br /> ------ ------------------------------------------ ----"„'-------+-----------,-..-.,---------------- --------' <br /> 0 1 1 PHONE 4 <br /> --- ---------- ---- _-...- -------------------+----.,-.--------------------------------' <br /> I .. I PRONE # <br /> f IIIIIflull{IIIIIIIIIIIillllilll----------------------------------------------------- ----------------------------------------i <br /> I / TANK ID # �At3K SIZE I SMI LS STORED CURRENTLY/PRFVIOUBLY 1 DAT$UST INSTALL= <br /> 1 (j ( /lJ I <br /> 39- r � 9� I <br /> { T l 39- ...-...,.. I �l <br /> f A i 39- I { I <br /> I K 139-___-1 <br /> +---11311 111111 IIIN 111IIIIIIII I I ITT[1lTllTirlT1 111{II1;IltllllljT1'Illlllllll{I rlTl"r III'II1 'E1' ISI <br /> L I APPROVED _APPROVED WITH CONDITIONS) DISAPPROVED <br /> A 1 (SEE ATTACHMENT WITH CONDITIONS) <br /> 1 N i PLAN REVIEWERS NAMEDATE <br /> +---1111{IIIlIlllll111111111 1-r 111111111111111 Tryf' lllll{►111!1111 lII111111Tliiililllll{Itllll{IIIEIIII <br /> APPLICANT MUST PERFORM ALL WORK SN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATION'S OF 1 <br /> I SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMXI•TTT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWTNO! "I CERTIPY <br /> 1 <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 /> 1 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES TRE <br /> 1 FOLLOWING: 11 CERTIFY THAT IN THE PERFORMANCE OF TR9. WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO { <br /> 1 WORKER'S COMPENSATION LAWS OF CALIFORNIA." 1 <br /> I ' <br /> I a I <br /> IaS SIGNATRE:APPLICANTOATS { <br /> 1 { <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 andate below. <br /> i- / ,�, 1 � � <br /> Name j ��t°✓� S �(W Address G '��lil-C l�`�1�t(rc uPhone <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 . <br />