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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,10 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 /> ------------------------------------------ <br /> ------------------------rFtb-------- <br /> EPA SITE M I PROJECT 6NTACT & TELEPHONE A IMIC NA 16` wA L-10/d <br /> __________________________________C______________._y___-_________________-____/-__________ <br /> F 1 FACILITY NAME <br /> ---_-(� I �,___ rO� W_-I5 ------------------------------------------------------- <br /> AI PHONE p � s}� grQQ <br /> w -------'i <br /> C i ADDRESS I TZ. S . C ��IZ!G�cG __ L�`i-'-- ----G O b_%. ----`--H------`-- -Z-`'°------------�' <br /> I ------------------------------------------ <br /> L i CROSS STREET <br /> ---------------'----'----'-'-----'---'----'---"--PHONE <br /> -#-------'----__----"------------� <br /> T I OWNER/OPERATOR G V I V S ro P V�'�XiL iL FJrS S"10 (o �'�.' Fro O <br /> Y <br /> �j <br /> --------------------------------------------------------------------------------------------------------------------------------- <br /> C I MNrRACTOR NAME i�/At L'r_o� E t�L G►wt c E(L k 14& �,c PHONE a ?!` - 3 }3 - l r L. <br /> '_-__ .-J� - ------------- LIC-------' ---------"---------"--------------------- <br /> ' N 1 CONTRACTOR ADDRESS P V - O O K I O�. 1 --- I I A Z <br /> CLASS <br /> 151: <br /> R ; INSURER C�Ar�I * WORK.COMP.M �1 T3/2 -4124` O �'' <br /> y,? T I Y <br /> i <br /> C 1 OTHER INFORMATION I <br /> ------------- <br /> i 'i <br /> PHONE # <br /> O <br /> I PHONE k <br /> 111111111111111111111 _____________ <br /> TANK ID q TANK SIZE i CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED i <br /> 39- 1011 10 FCO /A.f,�. UA(IL <br /> T 139- O L ! O Oo o 19 9 '/ <br /> A 39- <br /> j <br /> N ; 39- <br /> K 39- <br /> 39' <br /> 39- <br /> •--- <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S4 DISAPPROVED <br /> A (SEE ATTACHKE3jj WITH S) <br /> N ; PIAN REVIEWERS NAME \'�> - DATE <br /> to <br /> •-' iillllllllilillll111111111111111111111111111111illlillll ' II II II II Illlllllllllllllllllll�lil�llllllllllllllllllll <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORD , 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 THAT IN THE <br /> 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 WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE �R'�S �� DATE <br /> i <br /> --------------- -fCH --- / crTQ_t k--------------------------------------------------- <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 owner, <br /> the party must acknowledge this responsibility for the billin b signature and date below. <br /> p,p, �o io a s' qiG <br /> Name_ 19'6 9(_—Phone #_3 <br /> -- <br /> 1 <br />