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1� <br />r <br />SAN JOAQUIN COUNTY <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 />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />_TANK RETROFIT _PIPING REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />+----------------------------------------------------------------------------------------------- ---------+ <br />EPA SITE # ; PROJECT CONTACT E TELEPHONE # St- l GA <br />O�e'f • cis 1. SZ 2 . S I t0 ; <br />+-------------------------------------------------------------------------------------- - - --------- <br />F ; FACILITY NAME k,AISEa PEao-v%A6,� —iE# ZQQ . $Z S •& .T <br />C CA+--------------- ----- <br />C ; ADDRESS 14 DS <br />EM ITrG AVE. <br />------------- ------------------------------- <br />L ; CROSS STREET S 1 , b0M t f,tC *4Z. <br />---------------------------------------------------------------------------- ---- <br />T OWNER/OPERATOR PHONE # <br />Y ; K'A tse a -------------------------------------------- 7.09. '72S • 35 3 <br />---+---------------------------------- 3 ; <br />+----------------------------------------- <br />1 CO ----------------------------------------- <br />-CONTRACTOR-NAME <br />-- - E+'-R.O-- ------ -- I -- j, 1t P t:' -------- -------- I -PHONE-#- -IS i • S Z �.. -S110 <br />T +------------------- ----------------- --------------- -----------�---y---3-�'- ,,-- --- -=- ------- - ------ <br />--------------- <br />N CONTRACTOR ADDRESSP•0 3ox 23o 1.oruapatcA Vq-�CA LIC # CLASSA I <br />1----Q-------------' <br />R INSURER S t"AT'& FVA,A ��I9?Z p <br />C OTHER INFORMATION <br />T+-------------- <br />O ; <br />PHONE # 0151. S ?r �. SII o <br />R+----------- <br />+---I......'..1;...;I1..'......... -------------------------------------------------------------------------------------------- <br />PHONE # 9 z s• is 3. os 9 t -_ <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- bcN TAMCdatd•b,,a <br />T 39-—� — <br />A 1 39- <br />N <br />9'N 39- — — -- --- --- <br />K 39- <br />39- — <br />39- - — — <br />P .. <br />L APPR VED APPROVED WITH CONDIT" ,(S) DISAPPROVED <br />A ( E TACHM WITH COND TIONS) <br />N PLAN RBVIHWSRS NAME /1 �---- --- „ „ DATE <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 WIR FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br />BECOME SUBJECT TO WORKER'S COMPHTION LAWS OF CALIFORNIA.• CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING: "I CERTIFY THAT IN THERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CAORNIA." <br />APPLICANT'S SIGNATURE: <br />------------------------- <br />BILLING <br />- ------- <br />BILLING INFORMATION: <br />TITLEt"w�+� `"� M'I'%A 'LiESQ DATEt_ <br />---------+ <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br />coverage per tank. If the parry 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 />Name'Se,-Otl GoyIt <br />Signature <br />EH230038 <br />(revised 1/31/02) <br />Address 3H10 aa. <br />Asts*.A WF.Lioy Phone #gSt•S2Z•Stld <br />2tVl.2stpEtc-A -q2Sol <br />L 1 <br />Q +2�1 W� <br />AU � <br />- <5 <br />u <br />Atop V(,'� - <br />