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-SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT . <br /> 304 E WEBER AVE,3R4 FLOOR. <br /> STOCKTON.CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT.OR PIPING REPAIR PERMIT <br /> THIS PERMIT.EXPIRES 00 DAYS FROM THEAPPROVAL DATE, DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> __TANKRETROFIT PIPINGREPAIRIRETROFIT_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> *-------- -- --------------------------.... -------- -------------------------------------------------------------- --+ <br /> i 1 •SPA SYTE # �i PROJECT CONTACT 6 TELEPHONE # i <br /> i +----------=-- ...... ------------------------------------------------------------------- <br /> I <br /> --------:----------- .- ------I F i FACFLITY NAME PHONE 6 <br /> , <br /> L----------------------------------------- ----- ----- .�. ------------------_---___u. --. �... __--_�__�_u......- <br /> C i ADARE66 e <br /> I += -; C . _j�t l/i_ 4 5--53' <br /> _ _ <br /> I. L 1 MORE STREET- - --l - - - ----- ---__--.,.-...-----------.. i <br /> CROSS <br /> iI ------------ - --_ ....... .------------ 1 <br /> 1 T i OWtQ /OPERATOR`-�I�UM� i PHONE # <br /> i- -+-----------=------ -- -- -------------- -- --------------------------:"----*-- ..- y-�_- ---------1 <br /> C : COEMRAOTOR HAMS S S �-) 1 PEONS # 0`21 • 3-�- <br /> ! N + CONTRACTOR----------ADDRESS /d,q`o®rA___ Q�61__�e1 L I`��-I-CA S.IC 8 10 1�7----_--tLAss�&c�,�1 D�,�MAz-41C <br /> RR + xNBVR$R kA 1 . fwAr� _Y FAY"5 44ts���°a. 5 6&s_ -----� ..-. ..r NORK_COMP <br /> i C 1-OTHER INFORMATION 1 <br /> i T +-----------------•-------------------------^' ---------------....-----. -----........"'---------------••--------------......... <br /> i <br /> 0 i 1 PRONE 4i <br /> i R *------ ----------------..-----`------------- ,--------------------------------------^�-------- ------------ <br /> ------ ....... <br /> PRONE ...•-� <br /> --milli 11,11111,1111111111 lilimt-—------- ------------------------------------------------- ---------------------' <br /> .TANK ID 4 SIZE : CHEMICALS STORE4 CDRAE14 LYJPREVIOUSLY 1 DATE UST INSTALLED 1 <br /> 1 39- <br /> : T <br /> : A <br /> i 39- ! 1 <br /> ' ! I <br /> i ' 39• I <br /> +m�•1i!!i:!!!:)11'Ii1i1:!i:!ii!iiiiii:ii:1::!!iii!(ii',i,iiiiii!iii!!:11!I!!ii!iliiiiiliilll::iiiiiiii''r'riii!!!I:I1i!!,iiiii!ii:!i:!j <br /> 1 L1 APPROVED NITS CONDITIONS) AI6ADPROVED <br /> (SEN . <br /> 1 A 1 ATTACHMENT WITH CDa7DXTxON6) i <br /> 1 N PLAN REV.z mks:IQ$ME ovsD BATE \0 <br /> 1 1 " , <br /> 11 <br /> I , 1 <br /> AP7LICbHT MUST.PERF )MORA IH ACC NITX BAN &O AQDIN COUNTY ORDINAWCffi6, STATE LAWS, AND ARLES AND REUULATIC= OF 1 <br /> SAN 70AQVIN COONTY, EHVIRONM1F11TAL I ALTH ARTMIENT, OWNER OR-LICENSED AGENT'S SIGNATURE CSATIFIES THE FOLLOWING: "I CERTIFY <br /> TRAT IN THE RERFORMANC& OF THE WORK FOR WHICH T=l - PERMIT IS S68UED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS To 1 <br /> i SECOME 1U3=CT TO WORIER16 COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CSRTXPIWS T <br /> POLLON=d., "I CERTIFY THAT IN TSE PERFORMANCE OF THE WORK POR WHICH THIS PERMIT IE IS*VZD, I SHALL EMPLOY PMRSk1S ONS ,OBJECT TO I <br /> I WORKER'S COMPELTWICN LANE OP CALIFORNIA." i <br /> i <br /> 1 • <br /> J. innT.TnHmfrt wrUnRlfTfl111 TT11IB <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHQ 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 /> ?IS la <br /> Name �111�(�2�kGddress EQtUiUo ,F _ �Phone# ' g-d45-663 <br /> Signatures �� ! <br /> EH230038 <br /> (revised 1/31/02) R, 90E <br />