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0130/2008 ION 13:34 FAX 2099780 RANCHO SAN MICIIEL 21 f�003r 003 <br /> r 41)Y400 `,'.jU J FHQ --- ykOC};tQfi $Sx'V Sea 8q Cr. �CO3/Oab <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN CCM LINTY <br /> 60(1 F.Ttst 11'i;ain Street,Stockton,Califuruia 95202 <br /> 'I'dopholle: (209)46F-3420 lax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR Pr:Rmrr <br /> TNI$PERMIT-"AGS 300 DAYS FROM THE APPROVAL GATE, fF!=ATE PERV,17 TYPE(3ELOW. <br /> 'IYn�,rE511 gTil �Fl +rs3.tEN l;1r kTf,G�Ir !.,IUCr rV1,PNAlF[ETROl:T I ICAC BTARTIEVR UPGRAOC <br /> A EPA Sre 11 --J Prpjecl GgFliGet R 7P12Phona = � {�[_ <br /> ......... ...___ _� Lam+_ <br /> � f�acllily Nrlrnp ��—��� <br /> Phare <br /> Cross Slrael <br /> rt J+r1.0 • ... r F'lonet� rf --C,/0 .... <br /> 0 C-mtrectCt Nam 1 <br /> © --. C tCl= / j Phone ifs <br /> T _mIrIclor Address s� `�- . CA Lic# <br /> A )usure�sce�rh� <br /> �;�uj;L <br /> Work CompT It I <br /> oExpiration Date <br /> a ICC hislr tiers CBrIifICgU01t[Vunrlsrr �w Expiration Daly <br /> Tank IC r, Tank Sizeii Chernloals Starer) D9la VST lnsraued <br /> _ _ M CurrenI ylPreviously <br /> A . -- <br /> L i pproved vAth condl im I lDL;appn7ved <br /> ee Al achmP nI WJth'�On'ItiOn5} <br /> N r� <br /> Plan RGv:ow-,(,L-L Name r <br /> APPLICANT-SWAT KRFrlFul 64L WORD IN ACCORDANCE WiTH SAN JOAGUIN CCN IY ORCINpNCIO$,$TAT&LAwS.ANQ RULES Mid RreaULVIONS Or 3/,N <br /> JOAQIJI14 COUNTY,EWRNI&tENTAL HEALTH C)IPARTMCNT.OWN>R DR LICEW-M AGENT$81GnATURC CGF4Tlr1@9 tHC FoLLIOw1NG: i CeRTIFY TWAT Ib <br /> rH.E PERFORMANCE OF T64E WnRI(FOP WHIRR TMt9 pGRMIT IS ISSUEO,I SHALL N07 ELIC"LLS1r ANY PervZON IN SUCH A MANNER AS TO 4EC(NE SUBJECT TO <br /> WORKEWS CO4IPEN3A'nON LAwV OF QALIF0AWA.` 00iUPAGTORS HIRING OR SUSOONTRACTINO 616NATURI:CERTIFIES THE FOLLOWING; I CZ�T)Fy <br /> ThAI IN THE PC VC)"AANC@ OF THE WORK Fbft WHICM TW4 PERMIT 19 ISSUED.1 SMALL EWWY PERSONG SUBJECT T{1 WORKER'S aWPEN�ATIQN S <br /> OF CALIrORNIA.- UIW <br /> �DvYcanl!A5 h�Mlure_--- .._--� �,.,: ..,Tllk+ ,_�.�3aler„ �.,w.• <br /> UILLING INFQRMATION', <br /> lri6c3to the responsible r81y to be billed for addlWna!EHD sla'ff lime expendsd beyond penult payment tOverege par Iarlk, ff <br /> lha Plriy de5f9nalarl hClow Is different than llte pormR pppAcanl, e.g. property Owner, the party Alum! acknowledge IM, <br /> r*5P0WlNllly for Itw-11 Tr)rg by Sign,'ALWa and date bt!low. <br /> �.._, I"IbNE S <br /> ACI la-1 s U. <br /> -7�icNAruRE_ - - <br /> Eh12,ir 1311(revJsed 1;^.r311U1) <br />