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Jul 07 06 09:47a Jeffrey C. Henletl 714-739-1499 p.14
<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 DA'L'E. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW:
<br />_------------------------- TANK RETROFIT PIPING REPAIRIRETROFIT UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT — —+
<br />——`----!------------------------------------ ------------ �y}
<br />+ _
<br />--------------------------------------- {--PROJ---ECT---CONTACT---- & TELEPHONE # _���
<br />SITE #
<br />—�`L� ____,_PHONE #
<br />F ; FACILITY NAME _--_---;
<br />C ADDRESS
<br />L CROSS STREET '
<br />I +--`----------- - PHONE
<br />T ; OWNER/OPERATOR1 ^ a,y,4q
<br />Y 4.- C7 �J./ `4 a ` — c , 3
<br />-
<br />PHONE #
<br />; C ; CONTRACTOR NAME -T'� F.,,�---y-� � _ ® yrQ7 °_�`_�`_L_�•�
<br />N ; CONTRACTOR ADDRESS ! CA LIC # Z�1%S. S_____CLASS_d Q /• �t�y��
<br />----------------'—sv _ ^�_%_iras. iF - -------------------- t'6 t --
<br />WORK.CCMP.# 4 ` ,�
<br />R INSURER 1�.!_�_'_ .i�--'�.7 !'�.�G�----- +-------------- ----°�'� -- ;
<br />A-----------"----- - ------ ------
<br />I C ; OTHER INFORMATION
<br />T--__________ -------------------____--_-----------------------------------------------
<br />1
<br />--- _--_-------------------------;.
<br />OPHONE #
<br />R+___________________________
<br />PHONE _#
<br />+---1
<br />TANK ID
<br />CHEMICALS STORED CURRENTLY/PREVIOUSLY____-_DATE UST INSTALLED
<br />D # TANK SIZE
<br />39- ..r'1V-- uc=
<br />T 39-
<br />A 39--
<br />39-
<br />39-
<br />39-
<br />........
<br />9
<br />N 39-
<br />K 39-
<br />39-
<br />' 39 ,.,�,..,,,,.
<br />............. r 11111;t,;l;;r;;;.;11..;.;......,,..1'.,.,,..,,
<br />P 1
<br />L 1 APPROVED APPROVED WITH CONDITIONIS) DISAPPROVED
<br />A (SEE ATTACHMENT WITH CONDITIONS)
<br />NCtH ,PLAN'REVIEWERS IIAME
<br />............. .,,,,,��r,,,,,.,DATE® C,,.i,i.,,,,,,
<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 COMPEiNSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE
<br />FOLLOWING: 'rI 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 />C('i.1 T' DATE
<br />,
<br />APPLICANT'S SIGNATURE: "''�- TITLE
<br />-
<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_2n ddress 411,6.5 s Phone #1 ij g- �� x`r
<br />Signature
<br />EH230038
<br />(revised 1/31/02)
<br />
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