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/28/2004 16:30 20946 33 <br />FIFTH FLOOR PAGE Oe <br />ID <br />SAN JOAUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENTE- 2 1 2004 <br />304 E WEBER AVE, 3" FLOOR <br />STOCKTON, CA 96202 7 <br />E NV I rKO <br />APPLICATION FOR UNOERGROUNO TANK RETROFIT, OR PIPING REPAIR PERMIT�..ii <br />r <br />THIS PERMIT EXPIRES 20 DAYS PROM T�APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYPE BELOW <br />....... <br />_,TANK RETROFIT _ PIPING REP —UNDER DISPENSER CONTAINMENT REPAiR/RE7ROFrT <br />............................................................................. ; ---- - ------------------------- <br />EPA SETS #,O -PA <br />(20(p 1 Ij r;?. I PROJECT CONTACT & TELEPHONE N <br />-- <br />........... <br />FI FACILITY NAME <br />A ............... ---- Cki.'r- <br />C -P ............. - ---- ------- ...... ------ --- <br />- ----- .....C>Cll PHONE . <br />I S 6 <br />------ ...... ---\. I ....................................... <br />L CROSS STROET ?T <br />f� g- oL . <br />I............... --------------------------------------------------- ------------------------------------- <br />T OWNER/OPFRATOR <br />y <br />... - - u�%k�_ry .......... ................. --------------- <br />CONTRACTOR NAME I PROVE 0 <br />C <br />0 ---- <br />............................................ -------------------------------------- ....... <br />CONTRACTOR ADORES SE; lb?.Zpr I <br />..,j t I I CA LIC 1, <br />T...... <br />A ....... ORX.COMP.0 <br />...... ...... .......... ............ <br />R INSURER. I W <br />N_ f <br />J C I OTHER INFORMATION <br />............................................... <br />101 1 PHONE I <br />R...................................................................................................... <br />I PROVE # <br />+ 11111IM1111111:1HIMM11 ......... ............ .. ........... I ................................................... <br />TANK ID 0 TANK SIZE CHEMICALS STORED CVRRXNTLY/PArVjQuqLy DATE VST INSTALLED I <br />�1 S <br />39- <br />39-- <br />39- <br />N 1 39-- <br />X 39-- <br />39- <br />3p- <br />111111 11r[ITFITUT91-MI1111 III HI 1111111111111 m 111: 111, <br />APPROVED APPROVED WITH CONDITION(S) <br />DISAPPROVED <br />N I PLAN REVIEWERS NAME (SSE ATTACHMENT WITH CONDITIONS) <br />DATE <br />APPLICANT MUST PERFORM All, WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAdUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'r CERTIPY <br />THAT IN THE PERFORMANCE Of THE WORK Fr LAWS WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br />BIICOME SUBJECT TO WORKER'S COMPENS 0,; AT Of CALIFORNIA.* CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING! 'I CERTIFY THAT IN 0LMANCE OF nM WORK FOR WHICH THIS PERMIT IS ISSUM, I SHALL EMPLOY Pr_R3QW6 SUBJECT TO <br />WORXERIS COMPENSATION <br />PPL,,,,T,, TITLE <br />ATE: <br />'tt�� <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 />�11ame <br />Signal <br />EH230038 <br />(revised 1/31/02) <br />1 <br />hone # ooq ­qE .3 - �2 <br />