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SAN JOAQUIN <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3PD 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 REPAIRTRETROFIT UNDER DISPENSER CONT AIRIREfROFrr <br /> ----------------------- --- <br /> BPA.SITE# : PROJECT CONTACT &TBLBPBDN8 # <br /> F : FACILITY NAM- _ ----- --- <br /> __-___ <br /> C 1 ADDRESS .�3i1 __--_ � t _ !/!!eR% -- 9 --- --"r-`•'' --------------------------- <br /> :. _ <br /> T7�� <br /> 1 L 1 CROSS STREET � S.L_ -_---' --- <br /> - ----------------------------- —_--r— <br /> PERATOR <br /> ;Y_ O.(d11C'�a��__�,:�.'r � "�-'S-- �`--�--- ---_„may-------PFe� # e <br /> 1 <br /> + --- — 1 <br /> C : CONTRACTOR NAME , <br /> �nj �,n �v 'J i rl' :1 1 ca►Lxc# r��1r-� ,_- --�/ ' CJ CA C� �• . <br /> 1 N : CXINTRACTOR ADDRESS <br /> , <br /> : R ' INSDREft <br /> 1 C : OTHER INFORMATION -----------p- --- --_ <br /> ------------------------------- <br /> T +-_—_-_---_-------_---_--___ ' PHONE# <br /> ---------------- __-____- <br /> - <br /> +---1::11:1111:::::1111' ..,•.... PHONE # <br /> --------------- I STORED CORREN'II.H/PREVIOUSLY DATE OST INSTALLED . <br /> TANK ID $•• TANK SIZE ; CHEMICALS <br /> 1 39- <br /> 1 T 1 39- <br /> 1 A : 39- <br /> 1 <br /> ' N 1 39- ' <br /> K 39- <br /> 39- <br /> 39-L •,""•„•"„1„1,,,1, I;:IiAPPROVED:••, APPROVM WITH CONDITION ISI, DISAPPROVED��® ��� . <br /> Au _. IS ATTACHMENT WITH CONDITIONS) <br /> ' N PLAN REVIEWERS NAME:777•. �1 ,,.,,. <br /> ..... ......... ......•...•,...•...,,•.....•,,.,.•, <br /> • • ";1:1;1:111.,..,.,•.... ' <br /> APPLICANT MOST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAROR <br /> COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF - .. <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL.HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES IN FOLD: "Z CERTIFY <br /> SUCH A MhNNER AS TO <br /> THAT IN THE PERFORMANCE OF THE WORK FOR MUCH THIS PERMIT IS ISSUED, I S EMPLOY ANY mcTING SIGNATURE CERTIFIES THE <br /> BECOME SUBJECT TO NORKER.'S ON LAWS OF IFORNIA." PERSONS SUBJECT TO <br /> FOLLOWING: "I CERTIFY THAT IN THE CVO THE NORK WHICH THIS,PERMIT IS ISSUED, Z SHALL.EMPLOY <br /> WORKER'S COMPENSATION LAWS CALIFORNIA•" <br /> • APPLICANT'S SIGMA _ TITLE !1 4 �� <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 ddress. 3; /- Phone <br /> WD-517 <br /> Signature _ <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />