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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 den Ste+ U\S �� <br /> +--- -------- ---------------------------------------------------------------------------------------/-----+ <br /> I EPA SITE # ; PROJECT CONTACT & TELEPHONE # wQ%-+(&VLLLLI/t L-�o�,-_p�3 <br /> +__________________________________________________________________________ <br /> ____ _____ ---------------------- <br /> F <br /> _______________ <br /> F ; FACILITY NAME a-J-T�L'e ��/�,t-,�.�r m <br /> s� __------------------------------------PHONE # 401 -\yQt- <br /> A +----------------- - --------------------- + l '------ <br /> C : ADDRESS SD ��.rJ �V• i�L•C'• �\ w `' Q /_ <br /> I +------------------ ----Qt7--- ------------- ----7-S ` ----------------------------------- ----- <br /> L ; CROSS STREET Q <br /> 1 <br /> TOWNER/OPERATOR PHONE # <br /> ---+ --------- X253-(��� - �37 <br /> -- yy ---C-t---��/��-.--c----{-�-� -- +-- --------------------------------- <br /> Cl, �Xy <br /> CONTRACTOR NAME- rVll--" , S tLtc �`_S,s"'�-vwL �LC. - .. ) PHONE 40 9-__� fp�3 Y <br /> O +--_________ "`_4444 ____ _ L--------------------------------------------------- <br /> ____ _________ ___________ __� __ __ <br /> N CONTRACTOR ADDRESS �'/\ CA LIC # CLASS <br /> A��e �{8 S I � D40 14Y <br /> T +-------------------- --------- ------------------------------------------ --------- ------------ ------------------- <br /> R INSURER WORK.COMP.# <br /> A ----------- fe ------ �vL,t ncvt_ seroc�c WORK. 1137�F glo <br /> C OTHER INFORMATION <br /> ________________________ _______________________________ <br /> O PHONE # <br /> , <br /> PHONE # <br /> ______________________________________________________________________________________________ <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> 3 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVED ")(APPROVED WITH CONDITION(S) DISAPPROVED <br /> N PLAN REVIEWERS NAME l IV� (SEE ATTACHMENT WITH CONDITIONS) DATE ✓!���O� <br /> APPLICANT MUST PERFORM ALL 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 I.S. ISSUED,. 1.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 SIGNATURES 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 CALIFORNIA." <br /> APPLICANT'S SIGNATURE: 1W&-LML,)Ll1 C1)t1''tA4.LL-j---CL; TITLE Cow-blta LLLQ C -WW.ATE <br /> +----------------------------------------------- <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 /> Name I-lCl�x4-iv\V,.W-W-�LA Address (�uvi i • , e qSj Phone # X68-3q3-4 63� <br /> Signature_ 1./cI,�t+=vLI <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />