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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTHRDEPARTM304 <br />2o06 <br />RD E WEBER AVE, 3STOCKON, CA 95202 <br />APPLICATION FOR UNDERGROUND TTANK RETROFIT, OR PIPING REPAIR PERMIT <br />Fs <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 REPAIRIRETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />+---------------------------------------------------------------------------------------------------------------------------------+ <br />r <br />EPA SITE # ; PROJECT CONTACT & TELEPHONE # <br />'6+----------------------------------�'1----------------------------------------------------------------------------------------- <br />I F 1 FACILITY NAME �n QC Q----- o� w JC- — �------- PHONE # <br />/ 7 <br />C ADDRESS /L` Ip ------------------------------------ -- �-(-�---��C-�= ---C - -6-1 S---- --------------------------------- 1 <br />L ; CROSS STREET <br />, <br />T OWNER/OPERATOR PHONE # <br />Y <br />---+------------------------------------ -- <br />C I CONTRACTOR NAME ---,-,— <br />/L k V�CSlL7Pc----------------------------------------------' PHONE # ' <br />N CONTRACTOR ADDRESS & C..)1.0--------------------CA_LIC -#-""'u 2 ((00--------CLAS-- <br />_L.2 , <br />R INSURERWORK.COMP.# <br />I A I -------------C-- l� - �- f- ------------------------------------------------------ -'S <br />-----------1 7iU ---------`-I <br />C OTHER INFORMATION <br />0 PHONE # <br />, <br />, <br />, PHONE # <br />---------------------------------------------------------------------------------------------- <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />T ; 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39- <br />+---' I I,II;; 1 11 11, 1 1111111 <br />L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br />A I (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME LGQ.I l -teen, DATE Oq- 2(c -OC / <br />. <br />+'---„ iii,,,r,,,r „ .,,,.r,,,,,,, <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />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 WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <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 />WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: TITLE Zi( DATE <br />t---------------------------------------------------------------------------------------------------------------------------------+ <br />BILLING INFORMATION: �-vv fC Ak r-ecct9 Co.,, <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 Phone # <br />Signature <br />EH230038 No Fupzr*k� RNs c -riot s �r <br />(revised 1/31/02) <br />OR <br />