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ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3RD 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 />+-------------------------------------------------------------------------------- -f-----�-+ <br />EPA SITE # yam$ �y®�® ey �j_-----_-.-PROJECT CONTACT &TELEPHONE # C_-_ 0 J���^Tp3Gj <br />Y! -_A0 L _ <br />A /------------------- <br />-------------- <br />F j FACILITY NAME �iC �` i PHONE # <br />A ------------------------ ---------- <br />____________________________________________________ <br />j C i ADDRESS � 9 Lr< h"F'c1 <br />.f <br />I +________________ _______________ <br />i <br />L j CROSS STREET `C S�L <br />T OWNER/OPERATOR PHONE # <br />I /^ <br />�--- •— <br />----------— -- --+----------------------------------i <br />C 1 CONTRACTOR NAME ! •4-i K ®! 6 L 0� PHONE # gg ® f� ® ,V- <br />0 <br />j — <br />@ ®V-------------------------------------------------------------- ------Y--- <br />j N CONTRACTOR ADDRESS I e_____r_ _ _lP jj Nl ____________! CA LIC # j CLASS j <br />T+______________________ _ _________________i <br />R INSURER i WORK.COMP.# <br />Ai_________________________ ____ __+____________ ___ ____i <br />j C OTHER INFORMATION <br />T+____________________ ___ ______________________ _______+________-_ _____________-_____i <br />0 1 1 PHONE # <br />R+_________________________________ __________________________+__________ __________________i <br />PHONE # <br />---------------------------------------------------------------------------------------------- <br />j 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 />P <br />i <br />L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED j <br />A EEA ACHMENT WITH CONDITIONS) <br />i <br />� N � PLAN REVIEWERS NAME DATE I• � � � <br />1 11 <br />�L� ��y`' ' <br />�ri ..... ,1i iii ...�.,Fd.... . . i„ . . i((yy��'"'' . l„. .. 11176111''1 <br />ii .' iiia 1 .. ”®a'."J,',,p. ..... . ...... �. l . yy....... i . . i . k. <br />I APPLICANT ST PERFORM ALL WORK I ACCORDANCEITH SAN JOAQUIN COUNTY ORDINANCES, STATE S, A � RULES AN I ULA NS / �� <br />i <br />SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br />j BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />j FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO j <br />COMPENSATION LAWS OF CALIFORNIA." <br />/71i <br />APPLICANT'S SIGNATURE: TITLE fan OL 'e. DATE (®)O O0 �{ <br />__________________ ___ ______________ <br />BILLING INFORMATION: <br />THAT IN THE <br />WORKER'S <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 owner, <br />the party must acknowledge this responsibility for the billing by signature and date below. <br />Name �,r-,a C ry Address 1536 &j -(4u-4,,, Soh ; <a Ssa,. yPhone # Ci u i) IV -/4-3 b <br />1 <br />