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11/10/2005 08:24 2094680 EHD • PAGE 04 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBHR AVE, eo FLOOR <br />STOCKTON. CA 9S2D2 <br />APPLICATION FOR UNOI:RGROUND TANK RETROFIT, OR PIPING REPAIR PP-RMIT <br />THIS PERMIT 15XPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WR►TE IN ANY SHADED AREAS. INDICATE PERMIT TYPE Rei.OW, <br />`!TANK RETROFIT Y, -PIPING REPAIRIRETROFIT _,_,UNDER DISPENSER CONTAINMENT REPAIRIRETROF►T <br />-- ----------------------------------------------------------------------------------------- <br />SITE # CAL- 000 ZO 6 Z1o4 Paa1EC•r CONTACT 6 TELEPHONE iI -Sege j--------� 32% -`--`---------+ <br />-- - ----------- ---------�_ / <br />_ __-- 209 Ool7 ---- <br />P FACILITY NAME A ----------- <br />/V I-- PRONE # <br />----------------------- --- --- ----- -------- <br />, <br />, <br />_r <br />50 ' <br />' C : AnnREsE , <br />, <br />I----------- ------ �------------ on <br />I x. CROSS STREET <br />T 1 OWNER/OPSRATCa-`------ �Fi / ( O I --------•__•- -_-^__------- -------------------- <br />Y I 1!l� --- ---e,rc/r)------------------------------PHONE #209)577_ <br />---+--------------- -- <br />PHOIM <br />I //---------------------- n n <br />C CONTRACTOR NAS �nJe-� _Furnp .zY' --------------------------------------------+------- _9 `�[ (Q ----- <br />D+----------------- <br />N ' OONT'RACTOR ADDRESS � -c ' I ---- <br />- {��/S.d ' p CA LIC # �f 2 CLASS <br />--------- ------ -- - ------------ <br />' INSDR�R WORK. COMP. fI ------------ <br />11 " __ <br />A i---------LZ-�53c�4.g---..----- ---- --- --- YJGK Z9! 439033= <br />-------- ----- <br />I C ; OTHER INFORHATIO¢4 <br />i T +___------ ________________________------------- ___..______ _____ <br />r <br />r <br />___ <br />�, ( I'Y1� I PHONE 11 <br />-- - <br />-------------- <br />01 <br />r <br />R �- - 4-------- --------_--- n e------------------------------------------ --------- b? 551- 855 <br />--------------------------------- -`-------------- <br />39• T!%D # TANK SIZE-CHW'XCALS STO ,D CURRENTLY/PREVIOUSLY DATE�USTTgIN TALLER <br />Z., DOD 1 —`—` `a-----' <br />T 1 39- LQL?�.. ;�rPrri:iim ti p <br />I A I 39- <br />N 39� <br />K 39- <br />39- <br />39- - <br />LOVED APPROVED WITH CONDITION (S) DxgAFPRO r�D ' <br />1 A iSEE ATTACHMENT w;TH CONDITIONS) <br />N I PLAN R-37IPMRS NAME <br />:;1:'.. IlI'Illlll:ll:r <br />DATE <br />r..r r <br />APPLICANT MUST PER-oRM ALS, WORK IN ACCOR CR WITH BAN JOAQUIN COUNTY ORDINANCES, STATE LAW$, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY, BNVYttOmmExTAL HEALTH TMENT. OWNER OR LICENSED AGENT'S SIGNATURE CIRTtr%EB T=om FOILOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK ?OR WHICH THzB PERMIT IS ISSUED, I S'YALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br />BECOME SUBJECT TO WORKER'$ COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S AIRING OR smcoNTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK POR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />qaVAPPLYCANT'B SIGNATURfi_ TITLE d. DATE I <br />----------------------------- ------`--------------------------------------`-----------------+ <br />BILLING INFORMATION: <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 />�Co��Ot�S a'r /moi PR3�Jt�. <br />EH23003$ <br />(revised 1139!02) 3 -jam --�I�.�a� �s� s tics, eV-5�\'Zi.� <br />1 <br />