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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE.3"O 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 /> - + <br /> r j EPA SITE # j PROJECT CONTACT & TELEPHONE # <br /> {} +---------------X-1--11--------------------------------------��------------- -�7�CK <br /> -7-� <br /> - --F j FACILITY NAME. A-10( ) 3� i PHONE # <br /> A ----------------- ------------------------------------------------------------------------------------ <br /> C <br /> ---------------------------------------C } ADDRESS H- r,>0 l2 AazI -------T --------- <br /> L j CROSS STREET <br /> j T { OWNER/OPERATOR { PHONE # ---- -} <br /> Y ; <br /> {--- --&,P--- 957- T---------------- <br /> C <br /> { <br /> { CONTRACTOR NAME- / �] �r� -------i <br /> 0 ------------ f' 1 �.r-/-�--V--------- --------_PHONE_#_Q_��_� j <br /> { N } CONTRACTOR ADDRESSVtt - - -IC 0 J <br /> { R j INSURER1 p k) -15 C ��� I WORK.COMP.#047 Z� p 4rO { <br /> { C { OTHER INFORMATION +-- ---- ---- --- --- <br /> { T +--------------------------------- '-- ---------:------------------------------------+----------------------------------------� <br /> { 0 ' { PHONE # <br /> R `------------------------------------------- <br /> -----------------------------------------; PHONE-�--------------------------------I <br /> Irl 1 1 1 111111 11 1 II_--------__ j <br /> +---11111111111111111111111111111111 ---------------------------'_-----_'_-____-^_-------------------------------------1 <br /> ' { TANK ID # i TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY } DATE UST INSTALLED ' <br /> { { 39- j { <br /> { A { 39- { <br /> j N { 39- } { <br /> { K { 39- <br /> { 1 <br /> { { 39- j <br /> I ' 1 <br /> +---{1111111 II 111 111 11 11111 1111 1111111 I 1 I 1 1111111 11 1 II 1 1 11 1 II 1 1 1111 11 111 11111111 11 <br /> IIIlllljll Illjllljlljlllll}1111 11111111{ Ijl � l{{Ijjllllllljlljl}11}11 Ij} 1 II II j}1{j jl 11 l{Ijjl{{{I{{Illjllj 111 II 111111 11 <br /> i P } <br /> r <br /> { L { APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> 1 A (SEE ATTACHMENT WITH CONDITIONS) i <br /> } N j PLAN REVIEWERS NAME DATE <br /> 1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULJITIONS OF j <br /> SAN JOAQUIN COMM, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY j <br /> j THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO j <br /> } BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> j WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> 1 1 <br /> ' 1 <br /> } I <br /> 1 ' <br /> j APPLICANT'S <br /> j SIGNATURE: � � TITLE <br /> DATE d j <br /> +------------------------------------------------------------------------- 1 <br /> BILLING INFORMATION: <br /> r <br /> Indicate the responsible party to be billed for additional EHD 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 /> Name Address &Ai �UI/ t�i� Phone #,.7 q Gyg,.3335 <br /> Signature40444 4777� <br /> L_ <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 . <br />