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Mar -20-07 10:41am From-Gettler-oInc +925 551 78 10 T-333 P.004/010 F-136 <br />SAN JOAQUINCOUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3RD F100R <br />STOCKTON, CA 95202 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT ES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW! <br />ANK RETROFIT PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />-------------�_.--------------_--^_--------------CO- .-. .,-..-------------- <br />--------------------------------------------- <br />EPA SITE it CAROODUSE979 PROJECT CONTACT & TELEPHONE # LIDPYMCKENZI>r 925 5517555 <br />*-------^----------------------------------^.-----------------------`----^------ ------------------------------------- <br />F I FACILITY NAME A TEICHERT & SON INC 93963716---^--- I PHONE II 925 551-7555 V <br />------------------------------------------------------ ------------------------- <br />C ADDRESS 120 FRANK WEST CIR <br />x*------------------------------------------------------_---------------------------------•`-----------------------------------' <br />L CROSS STREET <br />Ir----------------------------------------------------------------------------------) <br />T OWNER/OPERATOR PHONE # <br />y A TEICHERT & SON INC <br />------------------------------ —­ ---------------------------------------------------------------------------- <br />C CONTRACTOR NAME Gettler Ryan Inc ; PHONE It 925 551-7555 <br />Or--------------------------------`-----------------------`--------------------- ------------^-,•----------------------------- <br />Slew., I <br />N I CONTRACTOR ADDRESS 6787 Sle, Court, Suite J Ouhiln ' CA LIC IJ a , CLASS a,h,c-10,ha8,C57,C61,tl40 <br />IT*-----------------------------------------------------------------------------------------------------------------------------' <br />R ; INSURER State Comp Funtl ; WORK, COMP, II 828-2007 <br />---------------------------------------' <br />C OTHER INFORMATION <br />Tt---------------------------------------------------------`--------------------------+--------------------------------------- <br />0 ; PHONE # 925 651.7555 <br />R*------------------------------------------------------------------------------------*---------------------------------------- <br />PHONE <br />----------------^------- -----PHONE # <br />,-------------------------- <br />, <br />TANK ;10 NX SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- - .. <br />T 39- <br />A 39- <br />39- <br />k 39- <br />39- <br />L APPROVEn APPROVED WITH CONDITIONS) DISAPPROVED <br />A I TTACHMENT WITH CONDITIONS) r7 <br />N PLAN REVIEWERS NAME DATE G <br />APPLICANT MUST FERPORM ALL WORK IN ACCORDANCE WITH ;AN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULPS AND REGULATIONS OF I <br />SAN JOAOUIN COUNTY, ENVIRONM"MTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S 9ICNATURE CERTIFIES TIIE FOLLOWING= "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR wxICH THIS PERMIT Is Is$=Z , I SHALL NOT EMPLOY ANY PRRSCN IN SUCH A MANNER AS TO <br />BECOME SUBJECT TO WORXER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />POLLOWING-. "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, T. ZFEALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPBNSATION LAWS OF CAI,IPORNI . <br />3/20/207 <br />APPLICANT'S SIGNATURE, TITLE Agent for Owner DATE <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional END 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 />6787 Sierra Court, Suite J <br />LIDDY MCKaN4E / ,Address DUW16 _ 04SES <br />Signature <br />EH230038 <br />(revised 1/31/02) <br />I <br />Phone # 925 551-7555 <br />