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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3"0 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 YITP7"REPAIR/RETROFIT ___UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> --------------------------------------------------------------------------- <br /> EPA SITE # I PROJECT CONTACT & TELEPHONE #��/ l / --gwe(!t _� -_f ' <br /> ,______________________________ __________________ (((��� ll---C l_ (Q �J_ <br /> ____ _ __ <br /> F I FACILITY NAME , G __ I PHONE �-i <br /> A +--------------- _�fl_a-,L,J ------------------------ --7---� k ��----�--I <br /> C ADDRESS ` <br /> I -------------- l - - ---------------------------------------------------------- <br /> L CROSS ------'�W_1V7 :1-�l <br /> Zr�___ ' <br /> T OWNER/OP��/Es�RRAAT�OXXR 4/0 <br /> -7 PHONE # 1 <br /> --------- ---------------------------------- <br /> C 1 CONTRACTOR NAME ( 1 PHONE # <br /> T N I CON'TRACT'OR ADDRESS I CA LIC # 1 CLASS <br /> 1 T +____________________________ _______________________-_____________________________________________________________1 <br /> 1 R 1 INSURER 1 WORK.COMP.# I <br /> C 1 OTHER INFORMATION i 1 <br /> T +____________________________________________________________________________________+_____________________________-__________1 <br /> 0 1 1 PHONE # 1 <br /> PHONE # <br /> ______________________________________________________________________________________________1 <br /> I 1 TANK ID # TANK SIZE 1 CHEMICALS S'T'ORED CURRENTLY/PREVIOUSLY i DATE UST INSTALLED 1 <br /> 39- 1 /,�,0� �7 <br /> T 39- i 1 <br /> A 1 39- <br /> 7 <br /> N i 39- <br /> K 39- <br /> 39- <br /> 39- <br /> +---II Ii II I11111111111IIII11111111111111111111111111111111111111111111111111111111111111111 I111111111111111111111111111111111111111 <br /> P <br /> I L I APPROVED _APPROVED WITH CONDITIONS) _DISAPPROVED <br /> 1 A 1 (SEE ATTACHMENT WITH CONDITIONS) <br /> N I PLAN REVIEWERS NAME DATE 1 <br /> +---1i 111 HII 111 HII 1 HIM!111111111111 ill 1111111111111111111 HH!HH!11111111111111111111111111!Mlill1111 ill H 11111111111111 <br /> 1 I <br /> 1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF 1 <br /> 1 SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY I I THAT IN THE <br /> PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO I <br /> I BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACT'OR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I <br /> I FOLIOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I I WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." I <br /> i <br /> i <br /> i <br /> i <br /> - I <br /> APPLICANT'S SIGNATURE: TITLE �l /�C�+� 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 owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name ---Address __Phone#_______ <br /> 1 <br />