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01%25;2002 •10:09 2094683# FIFTH FLOOR PAGE 02 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE <br />STOCKTON. CA 95202 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT. OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW. <br />_TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER. CONTAINMETNT REPAIRIRETROFIT <br />+---------------------------- ^ ------- <br />------------- <br />I EPA SITE # I PROJECT CONTACT i TELEPHONE # <br />I1I FLII <br />-------------------------------------------- <br />------------ <br />-'_-._-_• --_--� -- <br />FACILITY NAME --L1 PHONEk <br />A+------------------------- <br />C I ADDRESS 75-------------------------------------------- <br />---------------- <br />--------------------------------------%------------- ------- i3+ ` f �- -(- -�_------ <br />(�- -�--°--�i- <br />- -- <br />CROSS STREET <br />-------------- <br />C -1-- <br />-j' <br />---•- <br />T OWNr ZOPERATo -----------------------/-'�------------------ <br />Y��xrK 1 CCT I PHONE # 7000 <br />C I CONTRACTOR NAME ® T ------------------- " --------*-------- <br />O ---------' PHONL # <br />N I CONTRACTOR ADDRESS + - - '• CLASS <br />+------------------------ I -- LIC # I CLAS.. <br />R I INSURER I WORK.COMP.AI I <br />IA I----------------------------------- <br />C I OTHER INFORMATION 1 <br />T♦-----------------------------••-•---------- <br />----------- <br />0 1 <br />I R +-------------- I PHONE # I <br />IIIIIIIli111111111111111111i111 I PHONE # <br />-••• I <br />39-I�(pi •� _TANK SIZE I CI: ; S .. ORED CURR LY/PREUI fUSLY ' DATE UST' INSTALLED <br />39- til I V CWS1 >✓k�'�. iltit� <br />39YA01-4 <br />C? I I <br />39- it L I v I I <br />39- <br />39- <br />39 - <br />Ili H <br />9-39- <br />39- <br />IIII. i 11111111 IIIIIiIIII 1,1111TIllil IIIIIIIIIit m i llil I771-1177.Mllil1111111111111111111111111111TMi it I I <br />APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />(SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <br />+ --I IIIIIIIIIIIIIIH IIIA111HIll MilimillIlililiIIIII Ii mil 1111111111111 I IlllllliIII In III III III111111111111 <br />ji APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOP=IN COUNTY ORDINANCES, STATE LAWS, AND RULES AND RP3ULATIONS OF <br />SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMI3RT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING "I CERTIFY <br />I THAT IN THE 9ERFCRMANCE OF THE WORK FOR WHTC+i THIS PERMIT IS ISSUED, I Si[ALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br />I BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIE'IES 73ic', <br />+ FOLLOWING: "I CERTIFY THAT IN THE PERPORKWCE OF THE WORK FOR WHICH THIS PERM3T IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />1 WORXER'S COMPENSATION LAWS OP CALIFORNIA." <br />I APPLICANT'S SIGNATURE: _ 10— ACS as- I`-c� TITLE D+JkAilu W�W7MY11DATr OZIOD 02� <br />------------------------------------------------------------------------- -------- ---vim-------------_-------------- <br />BILLING <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 />Name6 <br />Signatu <br />EH230038 <br />1 <br />JAN 25 '02 9:10 <br />one number (70) 797 <br />2094683433 PAGE.002 <br />