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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 REPAIRIRETROFIT <br /> ----------------------------------------------------------------------------------------------------------------------------------- <br /> { I EPA SITE # { PROJECT CONTACT & TELEPHONE # { <br /> { -----------------------------------`------------------ <br /> { F { FACILITY NAME ----------------------------------------------------------- <br /> { A -----------------'----'-' - -----_' ---"--- ------ ---'---'-----� - __ '- - ---'- J----i <br /> { C { ADDRESScr <br /> s9 <br /> I I CROSS S -- ------ -----'-- - '-------- --- - - { <br /> L CROSS STREET � <br /> ------------------------- <br /> ----------------------------------------------------------------------------- <br /> ------ <br /> { T { OWNER/OPERATOR { PHONE # <br /> IYI <br /> {--------------------------; '- ----'-'--+--------------------------_---_--------- <br /> { C { CONTRACTOR NAME { PHONE # <br /> I0 +----------------- -----�5 - - -- -- -��-- ----- - - - --- ----------- - - - - "-------- -------I <br /> N { CONTRACTOR ADDRESS y �- - ® { CA LIC_#_ CLASS { <br /> d ----- -------------------- <br /> 1 R { INSURER I WORK.COMP. { <br /> { A {------------------------------------------------ <br /> --------- <br /> { C { OTHER INFORMATION � <br /> { T +-------------------------------------------------------------------------------------___----------------- <br /> -------------------- <br /> { 0 1 _ PHONE # { <br /> 1 R -------------------------------------------------------------------------------—----i PHONE- ---------------------------------� <br /> {---------------------------------------------------------------------------------------------- <br /> { { TANK ID # { TANK SIZE { CHEMICALS STORED CURRENTLY/PREVIOUSLY { DATE UST INSTALLED <br /> { { 39- { { { { <br /> { T ( 39' ' { <br /> { <br /> { A { 39- ' <br /> { N { 39- { { <br /> { K { 39- <br /> { { 39- { { <br /> -P-VIII Mi 11111111111111111111 11{11111{1111 I{IIIIIIIIIIIitIII 11{1{IIIIIIIIIIIIIII I IIIIIIIIIIII{I I{{I I II 11 F11,,11IIIII11I{11{j <br /> { L { _ APPROVED APPROVED WITH CONDITIONS) ^ DISAPPROVED 1 <br /> A I 11E ATTACHMENT WITH CONDITIONS) R aBa� <br /> { N I PLAN REVIEWERS NAME (r <br /> +---I11111II1111III 1III 11111111111111111{{1111111111111111 {1111{11111 111111111111111 III 1{It{01111 {111�111i1 1111111111111111 <br /> I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF { <br /> 1 SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY { <br /> THAT IN THE PERFORMANCE OF THE WORK FOR ICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO { <br /> { BECOME SUBJECT TO WORKER'S COMPENSATIOMWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE { <br /> { FOLLOWING: "I CERTIFY THAT IN THE iFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO { <br /> { WORKER'S COMPENSATION LAWS OF FORNIA." 1 <br /> 1 1 <br /> { APPLICANT'S SIGNATURE: TITLE DATE 1 <br /> { <br /> +---------------------- ----------------- ------.--------- <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tanIf the party designated below is different than the permit applicant, e.g. property <br /> owner, the partYi mst acknowledge this responsibility for the billing by signature and date below. <br /> Nam Address Phone <br /> Signatur <br /> EH230038 <br /> (revised 1/31/02) <br />