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01+/18/2005 17: 11 2094687 3 FIFTH FLOOR PAGE 04 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,30D FLOOR <br /> S70CKT0N,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 /> 'TANKRETROFIT PIPING REPAIWRETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> ---------------------------- <br /> ---- --ate-- ------- ---------------- -* <br /> +- <br /> EFA SITE (k PROJECT CONTACT A TELEPHONE 4 <br /> i <br /> _ _ -------------------I <br /> a <br /> I +- --------------•// // �j _I PROVE- OCA <br /> F I FACILITY. NAME- �1 171 /�_ - -- --------- ------------I <br /> C I ADDRESS /Y1 __ L.J.[r4= -L�3 A LA <br /> -- ----•'-----..-'------ ----- ------- <br /> I L I CROSS STREET <br /> 14.L�� .af-si /s// ----------------------------------I <br /> i 4---------------- - - �- •""'"/-�- ----/-- --- ------ -- PFIONE # /� { <br /> T ( OWNER/02ERATOR (i �n�-L /I vk'/�//� i/ ,i�T�,,L�" i (71LO&7V ✓LTJ <br /> X I wT'L/�(� /�,,T -------tip 1-�-------A--,.---------------- -PSONE # -----------------------------1 [� QQQ <br /> -C-I CONTRACTOR NAME-.. .J Q�� I�CJ�I�I v�i�l_L�j JJ -- '�---- <br /> ----------------------- !�- ,1_Q_ _1... <br /> --- - <br /> o -/---------------------/ /, - '//� - f1rYl� cx LI 7/-7/7'> I CLASS �{ y`l><{� IO <br /> N CONTRACTOR RD ESS J: Y�l.' - .407 1-.........- -----..... �-----. .-J-------i <br /> DR r/ <br /> -------"------ - -7 -7 <br /> T +.•----------------- ---- I WORIC.COMP-#• 1 7 r�� / _2�U� <br /> R I INSUR3R t ----------+---•------------------ ---- --- <br /> C I OTHER ImPORMATIO --- ------------•--- <br /> -'-'I <br /> ----------------------------- <br /> T ------------------- <br /> N ---------- -- I PEON # <br /> Io I -------------------------------------------------------------- <br /> R ---------------------------------------------- <br /> -- {IIIIIIIIITIuI�K1iDl {;IIIIIIIII�------------- ------------- --------- -'------- <br /> -•---------------------------------------------I <br /> TANK SIZE I CHEMI S <br /> -ISTO = CURRENTLY/PREVIOUSLY I DATE UST INSTALLED <br /> I' �<JO <br /> I <br /> 39- <br /> 3.9--- <br /> 39- <br /> N <br /> 9 39 39- <br /> N 39- I ; <br /> I K 139- <br /> 139- I I I ; <br /> ---IIfIIIIIIIII i ;111111 ;IIIIIiIiIIIII ililll IIIIII IIII ! I 17111: il ;I1. , V III HIM IIIIIII ili;Illlli <br /> P { <br /> L I DISAPPROVED <br /> APPROVE) AFPROVID WITFI CONDITION(S) <br /> A I (SEE ATTACHMENT WITH CONDITIONS) DATE <br /> I N I PLAN REVIEWERS NAME Iliii, illlll IiIIIII ,ii III{ Ii IIIIIII ii illi I <br /> ___IIIIIIIIIIIIIIIIIIIIIII IIIIIIiiilllllli IIIIII I Illli i III.. II <br /> I p•PpLI�T MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, TIFIES HE STATE LAWS, A•ND RTHE ANO REGULATIONS OF <br /> I SAN JOAQLTIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT- OWNER OR LICENSED AGENT'S SIGNATURE CERFOLLONING: 'Z CERTIFY <br /> I THAT IN THE PERFO&ANCE OF THE WORK FOR WsIICH THXS PERMIT IS ISSUED, I SHALL NOT EM2LOY ANY PE_C.SON IN SU01 A MANNER AS TO <br /> BECOME SUBJECT TO WORKSR'S COMPENSATION LAWS OF CALIPORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING; "I CERTIFY THAT IN THE pERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSU=, I Sk-=L EMPLOY PERSONS SUBJECT TO <br /> WORKZR•S COMPENSATION LAWS OF CALIFORNIA." i <br /> I 1 l d, 7 P/ � <br /> APPLICANT'4 SIGNATURE: j TITLE DATE � <br /> ..- --------------------'-------'------ ...-----.. <br /> -----------------------=--------+ <br /> �. ----------------------------------------------------------- <br /> •--------- ---- <br /> -------- <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit paymer <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. propert <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name Address Phone # <br /> Signature <br /> EH230038 <br /> (revised 1131/02) <br /> 1 <br />