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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,S"-FLOOR <br /> STOCKTON,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 /> TANK RETROFIT ____PIPING REPAIRIRETROFIT _(/_UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT <br /> ---------------------- <br /> c,:rr. - PROJECT CONTACT & TELEPHONE H L3 <br /> pep <br /> NAME PHONE Y �(' �_/_�^!` 7 f"1S _ <br /> -- ----------------------- r <br /> ` t <br /> a--w-----------T -+ <br /> E ,.,-.,-.-,S -;7.EET <br /> _ -4N---------------------------------------------------------------- _< <br /> _ �p,IEvIT PE�A.Ti�R PHONE k <br /> I <br /> `_ -Svgra_D ------------------------------------------------------------�r� �3�_ ---�--- <br /> { CONTRJt(-T^R NAME �- PHONE I v <br /> +, _ � L �_SSax - 1.�j-- --{-Yr-- - -- ----- -- ----- - <br /> ------------------ <br /> ADDR�'SS r ,.^` CA LIC <br /> ---cLas <br /> s <br /> ------------- -- Z�L�ti_.r �f`� - ^ �7 r,I+ <br /> WORK.COMP.# / / 3 C�C� ---- <br /> wuy-NO---------------------------------------------+----------------- -- - <br /> ------------------------------------------ <br /> -- - --- 'I PHONE # <br /> ------ PHONE 4 ' <br /> -------------------------------------`------- <br /> TANK SIZE CHEMICALS STORED C'URRENCI.Y/PREVIOTJSLY DATE VST INSTALLED <br /> I <br /> �I <br /> I <br /> illi <br /> I. APPROVED 1 APPROVED WITH C'ONDITION4. _ DISAPPROVED <br /> (5EE TTACHME T WITH CONDITIONS. <br /> ! LI <br /> IJ :r; REV 1EWER5 NAMEDATE �/ {r11 _ <br /> ' '- i Il A III III ' II hili li'i�i lII Ii II Illlilillllllllllllllllllllli i ..,ilii i ill <br /> APPLICAP"r MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN jOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> r'�TINTY, ENVIRCNMENTAL HEALTH I7EPA_RTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 1 THAT IN THE <br /> P3 F:'thI 'I-!E WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONPR.ACTOR°S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> . _..- "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> LANS OF CALIFOR2NIA." <br /> TITLE . .. �D.'E <br /> --------------------------- <br /> 00c_ <br /> -----------------------0 0 S•. e-t_ t S/ ids �(o�`u� �`�-- ' <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. property owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name --------Address__ Q'v ►'`�y-' -_--- ----Phone # S-5 3 ----��-� <br /> �'.., � S �l ►� CSI <br />