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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE.3""FLOOR <br /> STOCK TON,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 /> (2 <br /> RETROFIT _ PIPING REPAIR/RETROFI 1 UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> k PA 1'1'E M $H, e e t 1 <br /> ` pry { ^Y(�,`I �G; PRU,IF.0 T CON f A1'... I'E:.EPHONB re ,1{, !y � ���' „„I� �.• <br /> F <br /> FAC,:,i T Y NAME' V Fl lA� lJJ ;. n 1-3 <br /> U.f J G17 <br /> A /n�c + PHONE p - ry1 ®j 1 <br /> ADDRESS 9�V...3 Cc un I(J `�� . p n - ,�/( `i! T i£P�- <br /> .. <br /> CROSS STREET I 1 - <br /> OWNER/OP TOR <br /> v ��/�, <br /> k r i�6.eS .-C..S �- �'TN PHONE <br /> I .. ONTAC-T-O- NAME <br /> A_-E.. � �� os IqO" <br /> _ _ 7nry. PHONE <br /> "ONTRA7,a ADDRESS <br /> k. <br /> �01 I <br /> INSURER -_ _ -`.7..x_55 --. ":As: '^�J <br /> IZt, i <br /> 14 CII <br /> OTHER INFORMATION WORK.COMP p - <br /> /S� <br /> t� <br /> _.. ..--.. -. PHONE H <br /> "'ANY 11' A .. .. PHONE K... <br /> 1y. TANK alLh' HF.M!r•A. STORF,!I CURR <br /> 1 F.NT'.Y/PREVTOUS!v !)ATF. UST INSTALLED <br /> .I, `3 ' <br /> A 34- .. <br /> N 19. <br /> 19 <br /> 19- <br /> A APPROVEq AI P"wKi, - <br /> ISEV AITACHMF.N N.•I,1_C4.hYI':'1(IN :; DISAPPPO VED <br /> ♦_� PLAN REVIEWERS NAME I IT1;.)NSi <br /> DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN 1OAOUI `-UNTO tIPD .. <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPAR !NANO ES, STATE' :.AWS, AND RULES AND REGULATIONS OF <br /> THAT IN THE PERFORMANCE OF THE WORK FOR THINT, OWNER O1. .IcENSh> GENTS SIGNATURE CERT1F16S THE FOL <br /> BECOME SUBJECT TO WO WHICH TNIS PERMIT 1:; ;SUED, I SHALT, NOT HIMP LOWING: "I CERTIFY <br /> FOLLOWING: "I CERTIFY WORKER'S COMPENSATION LAWS OF,CALIFORNIA." i'ONTRACTOR'S HIRING ORSUB ONTRAERSONNG I SIGNATURE A <br /> THAT IN THE PERFORMANCE OF TI AS TO <br /> WORKERS COMPENSATION :.ANS OF CALIFORNIA." THE WORK Foil WHICH THIS PERMIT IS ISSUED, TUBE CERTIFIES THE <br /> I SHALL EMPLOY PERSONS SUBJECT TO <br /> APPLICANT'S StGNATUREalxi� ` � d- <br /> S ` <br /> . - DATE <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time e <br /> coverage per tank. If the party designated below is different than t Permit tended beyond permit pr <br /> owner the party must acknowledge this responsibility for a billing by signature and date <br /> ntt�el w. <br /> .g. <br /> Nam J" . <br /> c�deJ � s h .Address' <br /> �-e r��cx,-�' Phone <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />