COMPLIANCE INFO 2002-2006 - Laserfiche WebLink

Home Browse Search

Sep 09 04 09: 53a Mike Dotten (2091 533-2650 p. 1 09/09/2004 09:34 2094E 33 FIFTH FLOOR PAS 02 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE.3"0 FLOOR ' $TOCKTON•CA95202 APPLICATION FOR UNDERSMO'UIND TANK RETROFIT,OR PIPI11G REPAIR PERMIT THIS PERMIT EXPIRES 00 LAYS FROM THE APPROVAL DATE. DO NOT WRITE fN ANY SHADED AREAS-INDICATE PERMIT TYPE BELaw: TANK RETROFIT —PIPING REPAIRIRETROPIT UNDER DISPENSER CONTAINMENT RE PAIPJR FTROF7 •--------------------------------------------------.............--- I EFA SITE Y 1 PRCJZ= I Com-ACT ACT & TMNIONE..0 - ------------------ +.............IF I FACILITY WAME f-� FPO'' k a kZA-y L � 7©� ( 2 +----------- --------------- - --- ---- -- ------- - -- --- --------` g L I CROSS STR2ET I -------------.................^---------------------------------------- .............. ---------------`---------------------• T I oqN€R/QF&KAIOR -I PHO.HE e 1 I Y - 5"r� ' w tin c �� l r--I 1 `'� 3�k—izL -O i !-------------- -- •---- ^ S I C I CONTRACTOR MME a �..�L LES 1 PHONE a 532—'T 3 Z G------------------------------- I _- - 1 I n +----- ------------ ........................................................ ------ ---- ------ --- -----------•-I -P-O-- - I 13 I CbtSYRAC-MR AMRF95 1 CA LIC 0 cLA3v — ' I T --------- ----------- 1 _`T �3,.�:3 7Z=7Z�i%P__---. ----------------------------4 --I------- A-_ ...............� ey Cl I n -s i7'!y1Gr2 ( r�`I-- � ----------- ___._...---------------_caaP_n --`------- — -- f I - - - -I I C i ITUM INFORMATION I I IT •-----------------------------------------------1-----------------------------------------.—--------------------------- Q : 1 )'HOW p I ( R ---------------------------------------------------^---------------------------------*-----•----------------------------------� 1 PROM- a S 1 1 ---------------- ------------M1----------------------- ---- ---SI11((1111l1r11IIIII1111Ct111I11------------------------ � Ir"r SIZE I CNF]MICALS STgRID GVRR STI-Y/PR�J--OUSTY I DATE U$T LISTA.-Lffi Z 1 39'. &Z--[�- 1 2-C�, 0 CI C r 1 C �r�yS�`l L-/ t I ZG I I t X11-i q- I g Ar 39- ��,2t ? 'G1cFr; 1��r1y I 7nC.r - 9 N 1 39 g ! 1 39- 39- I I I I IIII 9- }9-IIIIIIII II !! I I..I:IIIII MIM jl ,t1111i1111.1II TF I Fri [III IIIF-1111 !IriI1111fllltllil! I�lilili1111!i' I L D APPROILAP RCVED WTYH 1+3I TONS} DISAPPROVE i A l ISE T UD ITIONS) i V 6IAN RzVrSWER5 NAME / _ DAT£ I -- IlIIIIi!r1I111111I111!� I I�� '-1 T IISII'!1!I'TT 11 �� r IIIIIIfI:II,I ,iiIII :i 11� 1 1 1 11 1 1; APFLTCAEYT MAST PER20RM ALL WORK IN ACCORDAYCE WITH SAN JOAOVIA COUNTY ORDINANCES, STATE LAWS, AND RVL£S ANL RRI71ATIa145 O9 1 CAN 70AQUIN COUN"., MWIRDHMF21TAL NZALTR O£PARTM2Tr. CWWE4 OR [,:CI?ISff7i AGMs-..-S SIGNATURE CERTIFIES THE FOLLOWLNG: 'I CZRT:FY , 1 TWAT IN TNR PE'RFORMAIYCE OF TnC WORK FOR WHil-i THIS PCNDIIT IS ISSUED, I 3IWL4 NOT EMPLOY ADR' FIMSOR CR SUCH A RANTER A$ rO 6L>C3ME 6IL83F-CT TO WOAX7a.'S COXPENSAYIOK LAWS OF CAf IFOULA.- C'OMTRACTCR'5 EIRSNG OR SUECONTRACLING SIGNATU", CT2T1FIE9 Ti{$ ; r'OLLOHINO: `L CEAT;PY THAT IH MX PERPORXAWE Or THE WORK FOR WHIC13 THIS PEMIT I$ 1;rU U. I SHALL :MIDLOY PER53NS SUBJZCT TO 1 WORKER'S CCN.PHNSATION LAWS 6F CALIFORti LA." S 1 � I 0 C/ I I APALLCANT"S S:v2+'ATCRE+ �� s 7.TLt DATE � I BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. Name f '� Address !^'i `lS`I Phone �3 'J �)Signature ) es EH230038 (revised 1/31102)