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r <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEN` ,� r <br />304 E WE13ER AVE, 3RD FLOOR <br />STOCKTON, CA 95202 �glcn LLLU JJJ <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT I I\f IRuVE(V "i HEALTH <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE P 7T' 4 ES <br />TANK RETROFIT _PIPING REPAIRIRETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />------------------------e--o--------------------+ <br />I EPA SITE # I PROJECT CONTACT & TELEPHONE # N A �? a 1� 1 <br />e,-----------'------------------------------�e--------- N ---- ---g--- Tu -----------{ <br />I F I FACILITY NAME `� Atte I D M { PHONE # { <br />iA +------------------------------ ------------------------------------------------------------------------------------------ <br />C I ADDRE I <br />{ I +----- ------------------------------I <br />{ L I CROSS STREET .. c - ` {3 ( t� _ id1 i� _ <br />I ----7 7� A --------------------------------------------------------------------------------------- <br />--------------- <br />T I OWNER/OPERATOR { PHONE # _ I <br />{ Y . A t (� opvc,TS L <br />C I CONTRACTOR NAME PHONE # b,� -AS ...... <br />" <br />N I CONTRACTOR ADDRESS „/// (�`"�-` + e A i CA LIC #{ CLASS <br />T+--------------------u-c30�2---- '-Ati -♦ Sa�I�+AL�1l���t-----------`,-� �� ------------- �c�L'�J-��r-�� --{ <br />R I INSURER /�T - i� y - WORK. COMP • # <br />A- T NU +_ 2 �9�1-�3---- -i <br />A �--- I � <br />I C I OTHER INFORMATION <br />-----------------------------------+----------------------------------------{ <br />0 I I PHONE # ---------------------------------{ <br />R+------------------------------------------------------------------------------------+------- <br />{ I <br />I I <br />PHONE -# <br />+---1111{iilili ii Ii I iii{i1li{I1------------------------------------------------------------- <br />-------------------------------- <br />TANKID#i <br />TANK SIZE { CHEMICALS STORED CURRENTLY/ PREVIOUSLY I DATE UST INSTALLED I <br />139- { { I { <br />T I 39- <br />A <br />9 A I 39- { <br />N I 39- <br />i <br />{ K i 39- <br />39- <br />39- <br />P <br />9-39 39-P <br />L { APP OVED ' APPRO N <br />WITH CONDITION DISAPPROVED A I ,_� -� ATTA WITH CONDITIONS) <br />N j PLAN REVIEWERS NAME : "" DATE YYY..��✓ <br />rUINC' <br />M111{{{{I{{{{{1{I{iI{i{{{{{{i{i{{iiii {{i{{{lrll Iiiiiiiill: <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS O <br />I SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CER�IFY <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 />i <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, 2 SHALL EMPLOY PERSONS SUBJECT TO � <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE:/ TITLE //V�� DATE 101.')-Q10 <br />1-------------------------------------------------------------------------------------------------------------------------.--------+ <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 bA N 46i C -ti 'TF0Address o 2%). U -14(fM A ?-00 Phone # a( 3 -qqi '35 1 -2 <br />Signature <br />EH230038 <br />(revised 1/31/02) <br />1 <br />