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06/09/2004 09:15 ' 20946834-3 FIFTH FLOOR PAGE 04
<br /> SAN JOAQUIN COUNTY
<br /> ENVIRONMENTAL HEALTH DEPARTMENT
<br /> 304E WEBER AVE.10 FLOOR
<br /> STOCKTON,CA 95202
<br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT
<br /> THIS PERMIT EXPIRES 00 DAYS FROM THE APPROVAL DATE 00 NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW:
<br /> ETROFIT
<br /> TANK RETROFIT _PIPING REPAIRIREfROF1T _UNDER DISPENSER CONTAINMENT RE----------------
<br /> - ------- ---------
<br /> -----------------------------------------------------
<br /> ----
<br /> }_ ____________-___ .-- ______EcT CONTACT i TELEPHONE 4 tN& -• -�'_
<br /> EFA SITE M : 9ROJECT CON L--
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<br /> �___- - ------------- ------------ � PEONS D --- __
<br /> r , FACILITY N'AAfE e_cP" ---------------------------------------------------------------------------------�-..
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<br /> ; CI}ADDRESS IL
<br /> -----"---------------------- ---------------
<br /> -----------
<br /> L CROSS
<br /> ______________-- -LCROSS STREET --
<br /> _-_---.__—___________________ F'-----
<br /> , PHONE X '
<br /> 2 ' OWNER/OPEPATOR ,
<br /> Re - --- 2HO ---------------------------;-
<br /> Y LJ E S i Cs S� Q,`J D - -1 �- ------------------�----
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<br /> c , cONTRAcroR NAME S. J i,.l F A V � S_�-----------------------....---------------- ,
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<br /> , N , CONTRACTOR ADDRE9Sr�-�11�L A � S i�.yR�_N 1�;,_.L_.------- - - ---..�-----'a-- _-._--;
<br /> T •------- -------- __ U'L 4s�--- - 1 NORK.COMP_ _�3--
<br /> R I INSURER � A - J L`.��-- ---- -----------�------------------------ t
<br /> A ------------------ _
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<br /> OTKER IvroRVATION ____.
<br /> -------------------- -------------------- '
<br /> PHONE P
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<br /> -------------------- PKONC R
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<br /> SITS CHEMICALS STOKED CURRENTLY/PRE-VIOUSLY CATE UST I.n7A1_ED
<br /> *---• ,.",,•,,• ., , .... .,.. TAv<
<br /> TANK ID A
<br /> 39-
<br /> 39-
<br /> A 39'-
<br /> N P'N 39
<br /> K S9-
<br /> 39-
<br /> 39- ..,., ,..,,, .., .
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<br /> _APPROVED WITH CONDITLON(S) DISAPPROVED
<br /> :SIE ?TTACHMENT WITH CONDITIONS) O(
<br /> DATE
<br /> A
<br /> R PLAN REVIEWERS N.�ME
<br /> +_-•:;;1111;•111:"171;S1ti 1111111:t;11:11: a;rK SAN .CADOIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULAT:CNS OF
<br /> APPLICANT MUST PEH ORM ALL WORK IN ACCORDAJ+^
<br /> 'T CSKT:FYTP1.: IN TIL•
<br /> SAN JDADU IN COUNTY, CNVIRGNMf-`I'=a= H�SA=11 DE?%V�->L•:t' ORtIER OR LI CEN:EO .�GCNT'S SIGNATURE CERTIFIES TRa FOLLOWING!
<br /> ics PERNIr IS =ssUfO, I SILV.L NOT EMPLOY AWWN IN SUCH A?4&:NEA A: TO T___ya THE PERFORMANCE 09 THE NORH FOR WWICN T' PERSONS SL-BjZr 0 NO"k-K
<br /> SECOM.E SUOJECT TO W`ORKER'S CCY,PEKSATION LAa5 0=cALI W RK FOR COHTFHICH THISR PERNIiI IS O SSOED OM HALL EMPLOY SIGNATURE ..
<br /> FOLLOWLNG:'I CERTIFY THAT IN :•KE PSH-MANANC= '
<br /> COMPENSATION LAWS OF CALIFORN=A.' A '
<br /> TITLE In
<br /> APPLICANT'S SICRATURE.
<br /> ---------------------------------------------------------------------------------------------
<br /> BILLING INFORMATION
<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. prop"
<br /> the party must acknowledge this responsibility for the billing by signature and date below.
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