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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3"0 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 'e- -'�c WL SC V- It tc�q <br /> =----------------------------------------- <br /> EPA SITE # PROJECT CONTACT 6 TELEPHONE # <br /> --------------------------------------------------- ____I <br /> F i <br /> 'II FACILITYNAME �` �0. <br /> PHONE # apQ <br /> � ______________ _ _ ___ - - �_ I_ _ <br /> _____ <br /> A +__________ _ t _ ___ __ <br /> C ; ADDRESS I SO J&ck, T0v1•Q- O, -G � CA (�Q <br /> I ----------------------------------------------------------------------------- � ---------------------- <br /> L I CROSS STREET <br /> I +--ROSS--TREE------ _------------------ ---'---------------------------- <br /> I <br /> ---------------- <br /> T ; OWNER/OPERATOR , PHONE # <br /> I <br /> -----------------------------------------C ``—— ----------------------------------- ------ �'�_-_ - l_- �a 7-------- <br /> . C.I CONTRACTOR NAME Sea L�- S CJL-IWU�.J 'S S i-VY�c ----O-� .. .. <br /> p,� �f + <br /> . 4'`-=-------"----=-----"-`i--=""l'N-�-'L----- -------------------------------------- <br /> N <br /> ---PHONE-# .. <br /> -p +---------`---------- - -- ------------------- <br /> 0 a N CONTRACTOR ADDRESS 0 _ �(�.�{ JRf$-------CA_LIC-#-��5,--a L4----------CLASS�l_ k`Nqk-� - <br /> f <br /> R INSURER fV�O .o�nt.� L.1L�-VLI.C`�'�/-n.� �0 (/�.. ,L(� -_� ----------- s�-� <br /> A �3 0 <br /> Lhi/�w <br /> C 1 OTHER INFORMATION <br /> T +------------------------------------------------------------------------------------+----------------------------------------� <br /> 0 ( r PHONE # <br /> , <br /> R +---------------`-------------------------------------------------------------------+----------------------------------------' <br /> PHONE # <br /> ---------------------------------------------------------------------------------------------- <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> A 39- <br /> N ; 39- <br /> K 39- <br /> 39- <br /> 39- <br /> +--- <br /> P <br /> L I 1,APPROVED, APPROVED WITH CONDITIONS) _1 DISAPPROVED 1 <br /> A 1 11(,EE'ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAMEDATE 117 <br /> / O <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> .BECOME•$UHJECT:TO.WORKER'S, COMPENSATION_LAWS.OF CALIFORNIA:": CONTRAGTOR!SHIRING OR SUBCONTRACTINGSIGNATUR$-CERTIFIESTHE -; <br /> - FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF-THE WORK FOR WHICH THIS PERMIT IS ISSUED,.'.Z SHALL.EMPLOY PERSONS'S(SBJECT'TO .. <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." - - <br /> APPLICANT'S SIGNATURE: `. [mow �J' / TITLE l{,1.WDATE <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 /> NameR"OL . yU�-et-'E� U.LwAAddress �Q�L QViUi�, � ,SS, 1 hone# 0V -,-)13- 03 <br /> SignatureC��-Q-�-ti� �� ` •-rz � � �ti �% <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />