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SAN JOAQUIN COUNTY <br />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 />+------------------------------------------------------- <br />-----------------------�---^-----------------------------------�1--- ----- <br />I EPA SITE # I PROJECT CONTACT & TELEPHONE # ,' ulA ` a <br />+___________________________________________________________________________111_���__111______________________ <br />F ; FACILITY NAME tA.v ( 5 A ,M, P I PHONE # I <br />_______________________________------------------------------ <br />C ; ADDRESS I � I -) �_ ` 7 a-7- A — ,7 <br />I+_________________________________________________________________________________________________ <br />L CROSS STREET <br />I+_______________________________________________________________________________________________________________________--_____ <br />T OWNER/OPERATOR PHONE # <br />;Y; j)Q (`1J�.i, Cz- g�, <br />---+ S �Qnoq �- �iq-(,7o <br />----------------------------------------------------� L-----------------S-7771-3--„--�- <br />--J--S--�- <br />----- - <br />; PHONE <br />CT+_C_O_N_T_R_A_C_T_O_R__N_A_M_E 1�C�i (r-�3----1Pr UoAC R <br />o +--------------------------- - -�-T----------- <br />--------------------------- ----- <br />------W------ <br />N <br />-----N CONTRACTOR ADDRESSLi A <br />u v (-- <br />CA LICi CLASS am3 An <br />H <br />R INSURER i i �� 1V WORK. COMP. # A L 1;)- 3 <br />A---------- _____________________ , 1 <br />C OTHER INFORMATION <br />T+_______________________________________________________________________________-----------------------------_____�_ <br />0 ; PHONE # <br />R+_____________________________________ _______________________________ , __________________________________i_ <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 />................. <br />P <br />L ji APPROVED APPROVED WITH CONDITIO DISAPPROVED <br />A W ( E ATTACHMENT WITH CONDITIONS) <br />AN REVIEWERS NAME �(/ <br />DATE 1(/?/Or <br />„ .......,, <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS QF <br />SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERT$FYTHAT IN THE <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY AEHS(RN IN SUCH A MANNER AS TO <br />BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT;TQ WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: TITLE A 112/—T DATE O J h5 h r <br />BILLING INFORMATION: <br />iIndicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br />coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, <br />;the party must acknowledge this responsibility for the billing by signature and date below. <br />ame Address <br />Phone # <br />10 l "7 c.t+"4.e P�1�zS�in3 C�.d,�loyd ws SXellcr�e ?�e dtoy.S <br />��xl n�4d <br />�/"`�'f' a %t vra+ d �a�» SiLoo3s35' �-, yN s�et.�� roue e,7 a.$ e 4 <br />