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-SAN JOAQUIN COUNTY <br />ENVIRONMENTAL, HEALTH DEPART I_ T <br />304 E WEBER AVE. 3P0' FLOOR.. <br />STOOKTON. CA A5202 <br />APPLICATION FOR WNDERGROUND TANK RETROFIT. OR PIPING REPAIR PERMIT <br />THIS RERMIT EXPIRE$ 90 DAYS FROM TMEAPPROVAL DATE. 00 NOT WRITE IN ANY SHADED ARW. INDICATE PERMIT TYPO 9IFLOW: <br />_TANK RETROW PIPING RZPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />------ ...... I-------_ { <br />-IPA SYTS # I PROJECT CONTACT & TELEPHONE # /9Q �( �C /%�i I <br />1 F +-FACXX.XTY "MAMA rj tL'�V w • - ------_- ---._r.nnn_- ----I _PHONE_# --------------- <br />=.4 V _3V —® 317 _ 1 <br />i +' -�- - --------------- <br />--- --------------------------------- <br />- - --- -- <br />t.0 ! _i <br />1. L (-CROSS STREET ___.nL.Y -..... ------ — <br />_--__-nw-- ---------- ---n.n. i <br />----------------------------------------------------- <br />I Y I .OWN& /OPRRAToR I PHONE #vt <br />i---}.....------:---U1.Vir(a--------ter.... = -------.._.. -----------•--n_—_*-__--_••- --- ---------i <br />i CeOuTRACTOR NAME 1 PROHS # I <br />! N : caiaTaACTOR ADDRESS_�YL_~� �3Q° ­----------------- 1t cA zIc e/,NQS'!-�jr�,------- ,Ass$ Cfgl1 D�(9�uA?1{IG <br />iT }_---_w...----_-___ - --- <br />IRA ;NEQR$R-1�.L.r n n- - "Sh2_`ezLY�aISJ. L�5 5LJ �4.r4 .KS _-----.......... 4-----------� <br />Ci OTHER INFORMATION ! i <br />I T *--- <br />--- --- ----- - -w --- -....-------- ---------------- <br />I PRONE <br />I R -------­--------------------- — -- 7 --------------------- -n . <br />PRONE #w.-- ••- ----- --- - <br />n --i <br />"------------ ----------------•--------------...................... <br />i I TANX ID # I vikxx SIZE ;-CHEMICALS STOP= cmuWTLY/PREVIOvzU 1 DATE UST INSTALL= 1 <br />A ' 39- <br />1 N 1 34- r��� <br />I t 34- —�t��• t i <br />I <br />i i 39- t i <br />, ..Si1i.i! hili 1111 lit! ll 11 Ilili::iitttt .I1i11::i1 1:!l.Il.i! ill <br />1. Ili <br />i I?I i <br />i L ! _ APPROVED APPROVED WITS CORDtTIGN(Si AIEst&PRQVED t <br />NAiNIr pl N� (SEE ATTACHMENT WITH CONn=TICKS) <br />!" N PLRN FsvIEMffitt5 DAT <br />E <br />-- _lSIIillti'!!{.ttt: isI.t!:;11;1 !'il'lIll.! t.tltl::li:lil!!!ilsitli!!!!it1.i!!I!!I;IIitit:lt!:11 ::1:11HII IIIII <br />! ! <br />I A*1?0 eM MUST. PERFORM ALL W= IN ACCORDANCE KITR $AN ZOAQUIN COUNTY ORDINANC28, STATE LAWS, AND RULES AND REGULATIONS OF ; <br />' SAN JOAevur Y, RuVIRMUMML E[€ L7X DEPARTMENT. OWNER OR LXCEW99D AGENT'S SIGRAT'ORE CERTIFIES THE FOLLOWING; "I CERTIFY <br />TWAT IN TME PERFORMANCE OF THE WORX FOR WHICH THIS FEFMIT IS ISSUED, I SHALL NOV EMPLOY ANY PEON IN SUCH A MANNER AS, TO <br />I BECOME ^REJECT TO WORXER.'S COMPENSATION LXWX OF CALIFORNIA." CONTRACTOR'S MIRING OR SOBCOFMCPING SIGNATORE"CFitT;FIffi T2W ; <br />FOLLOMING: "I CERTIFY THAT IN 279 PERFORMANCE OF TBS WORK FOR NMICM THIS PERMxT IS ISECED, I SHALL EMFLDY PERSONS "SUBJECT TO ! <br />i WORKER'S COMPENSATION LANE OS CALYPORNIA." t <br />! <br />1• 1nnT.TnitRmfn iiTrMh'Mr 1111 Tir6fi <br />BILLING INFORMATION: " <br />Indicate the responsible party to be billed fo*r additional EHa 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 S9n- j 2 A16q §pjL:Pddress 0.0 a U i 40 ,SGAlLkM Phone # qr) 9 _d45 '-O03 � <br />