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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 Se��UY <br /> +- ------------------- --------------- ---------------------- --------- �..�a,,�[, (� �,,,.``. <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # ��------------------------------ <br /> _�� a`,_- 40 a,_ °313„-f��?_I <br /> +__________________JJ_________________________________j__ _____________________________ -- �/ —- r[w <br /> F FACILITY NAME �6 y�4-- Z--T`7�U e.� tf-",-t ----------- PHONE # 0O 1_-SQQ_ `f/41--------� <br /> A +----------------Y---cr - ---- O--� - ---^-'-------- - ----------------------- l L - -- <br /> C ; ADDRESS i'J b i .ACk—r0Lte, �1,� I�LrDUV�__CQT ���� <br /> I + ------------------------------------ ----�} <br /> -------------- ------------------------------ <br /> --------------- <br /> LI CROSS STREET u <br /> I +---------------------- f--`4 <br /> q------------------------------------------------------------------------------------------- <br /> TO ONER/ ` YV J � S ► +� ""'�(�. - PHONE # <br /> Y Z � h 11a.✓1 <br /> 63 7�---7- - - <br /> CCONTRACTOR NAME_ � PHONE # <br /> + �_ _ K <br /> N I CONTRACTOR ADDRESS ��Q__Q V Z �A___A),e- -----------------CA-LIC_#-LIS!S-� ---___ _CLASS1,C bc_j bg40 i <br /> T +_______________________ <br /> R ; INSURERT WORK.COMP.# ' <br /> hal �SCQ L6lq_ its"---------------------+-------------�- ------(p--------------' <br /> C ; OTHER INFORMATION <br /> T +____________________________________________________________________________________+________________________________________, <br /> 0 PHONE # <br /> PHONE # <br /> ---------------------------------------------------------------------------------------------- <br /> TANK ID # TANK SIZE ; CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- IQ <br /> K ; 39- <br /> 39- <br /> 39- <br /> P <br /> 9-39- <br /> 39-P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A i v' 4S . ATTACHMENT WITH CONDITIONS) <br /> N ; PLAN REVIEWERS NAME �` I DATE <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 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'SHIRING 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 CALIFORNIA." r /'/'� <br /> APPLICANT'S SIGNATURE: �L �^''-`C-- (, (,,.� TITLE (0441(&U-0 `-' l«fir DATE ; 0 <br /> ' �l W-St- S <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 U1U4&',L-N Addretwt r-%4- 40- QSll Phone # Og 3—loc�3� <br /> Signature `q1A rLLttL,­' <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />