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0 <br />Ll <br />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 />EPA SITE #;__ <br />PROJECTCONTACT -&-TELEPHONE -#_�.HA,Q��c <br />�///A_( ry�------------------- <br />- ��J[� - s. <br />F FACILITY NAME_PHONE #-t( 2. L _ <br />1�--------------- <br />A+------------- ------------------------------ -- <br />C 1 ADDRESS <br />I 16 o r ---s '--- -L--� 02A��o--- 5T- ----------- S TO ClG--------9 SL O--O-----------------------I <br />' <br />L I CROSS STREET <br />I+ -OWNER -OPER------------ ` + <br />T OWNER/OPERATOR PHONE-#-- s r OL- -�� Z L <br />Y a a s Ar t,( �� 1L E_ <br />---------------------------------------------------------------------------------------- <br />C I CONTRACTOR NAME(,L - o •t ,--- ----------=-PHONE # <br />--- ---aarz, c- - `l/6 --_- <br />3 4- 3 <br />N ; CONTRACTOR ADDRESS 0 CA LIC # �,_Z 3- - _- -__CLASS A R (a A Z _ <br />p. 0 lab?( ro rA-s�rfl----------------------4---------- <br />T +-------------------- <br />---------- --- <br />R INSURERWORK. COMP . # OOQ } g Z <br />------------- <br />} pi�-- <br />A � T �4-- I✓ -- NO------------------------------------------------+------------------ - - --- - _- <br />C OTHER INFORMATION <br />-----------+------------------------------- <br />'------------------------------------------ <br />T +---------- , PHONE # <br />0------ <br />------------------------------------- PHONE # <br />----------------------------------------------------------------------------------------------- <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />T 1 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39- <br />P <br />L X APPROVED APPROVED WITH CONDITION(S) DISAPPROVED �/ <br />A (S HMENT WITH CONDITIONS) /J t➢ ,�J <br />N PLAN REVIEWERS NAME DATE G"yl'i'G/� f _ f <br />�.;`;II;;;;;;;I;;;;1 ;;1;;1;1;;1 <br />w ' eviwS�1 � ' � 'Goi�%►p1Q,}d` ; ' ;aJ+l; ; ' <br />APPLICANT MUST PERFORM L WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, 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 <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 />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 <br />WORKER'S COMPENSATION LAWS OF CALIFORN A. <br />APPLICANT'S SIGNATURE: TITLE l ©�'�'-iC'{,/{ Vh DATE <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 />WALT -04 'P -Q• BoK fozs- 7(6 <br />Name E;ik C, i u r., tja( m c4 Address W- S A-vra CA 93-611 Phone # 3 *� 3 - Il r L <br />Signature <br />_)ZlLb !�—av-& <br />EH230038 <br />(revised 1/31/02) <br />1 <br />