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SAN JOAQUIN COUNTY JAN 0 2 2003 <br /> ENVIRONMENTAL HEALTH DEPARTMENT ENVIRONMENT HEALTH <br /> 304 E WEBER AVE,3'0 FLOOR PERMIT/SERVICES <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 REPAIR/RETROFIT <br /> -----------------A SITE %_______________________________________________________________________ __� �, ----_�_/ <br /> PROJECT CONTACT 6 TELEPHONE % /J��� , �_________________1�7—Ls D 2 7 Z <br /> F I FACILITY NAME 4-� �-J -/( 3 _______________________________ PHS % '�"'�' / r - ` <br /> A ---------------__J./ 9 9 <br /> ADDRESS ves YN --11w-y----?I-------------� C d.\/----------------' <br /> I L ; CROSS STREET <br /> ----------------------------------------------------------- <br /> MONS ft <br /> Y OWNER/OPERATOR i'I C r7((i J rl JDI�LG�S LCLL� I J��3 - 263 -/l� __ <br /> __________________________________________________________*______-____-___-_______ <br /> ___*_CONT_____________________ .,/.{ } I PNONE q <br /> O CONTRACTOR NPME �Q/-/. N,/�,^�Nd_1U15'L ' "� S__________________________________________I <br /> O *-CONT"--_-_ __ ].R - p C_ CA LIC % �='A�SgOO�PJ I CLAESC/D 8_(}_�}5 of N lC <br /> N i CONIRACIOR ADDRESS//j,/ _ ._ � �'_IIy 77?(__�.7�J�T.>�jQ.-�yf____________________!.'_____ <br /> T --------------------- <br /> R <br /> ------- - �^ WORIC.NMP.k (j IZ GUOU/ 501 <br /> R 1 INSURER {../Y+// (iL� ----------------------- <br /> -l/ t __�4_Y!'IS?_'s.1r_ �IP_------ ------ ----------------------- - - <br /> C OTHER INFORMATION <br /> _________________________ <br /> T -----------------------------------------------------------______________________________ <br /> -E % 7/y-.560__ <br /> R *__________________________________ 8 zz <br /> __________________________________________________ _--- <br /> PHONE % <br /> I <br /> Illlltlll Ilrlll I______________ _ _.STUN__ <br /> *"--Iilliilllllllll1iilll a Illi TANS SIZE CHEMICALS STORED CURRENTT.Y/PREVIOUSLY i DATE UST INSTALLED <br /> TANK ID p I <br /> 39- ' <br /> T 139- <br /> A 39- <br /> N <br /> 5 N <br /> R I' i <br /> 39- <br /> 39- <br /> I <br /> P <br /> I L APPROVED APPROV® WITH CONDITION(5) OZSAPPROVID <br /> A /11/ �E ATTACHMENT WITH CONDITIONS) LP+TE I_lO �D <br /> I N PLAN REVIEWERS NAMe <br /> 'IIIIIIiIIIIIIIIIIl ;111111111i1I1ilIII;11;1;11111;;11;11111 III'Illlllllillllllllll:llllllli <br /> APPLICANT MUST PERFORM ALL NORR IN ACCORDANCE WITH SAH JOAQUIN COUNTY ORDINANCES, STATE LANE, ANO RULES ANO REGULATIONS OF <br /> ENVIRONMENTAL <br /> SAJOAQUIN COUNTY. HEALTH DEPARTMENT. ONNPR OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY I I THAT IN THE <br /> SAN OF THE TORR FOR WHICH TRIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSCH ON IN SUA WANNER AS TO I <br /> PERNA JOAQUIN <br /> AHCE <br /> BECIX� SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA, CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE WORKER'S <br /> I FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE NOHR FOR WHICH THIS PERMIT IS ISSUED, I SHALL EF@LJY PERSONS SUBJECT TO I <br /> COMPEN5ATION LAWS OF CALIFORNIA." <br /> 1 <br /> �`Owyo%a.v Fe. <br /> APPLICANT'S SIGNATURE: <br /> .n _ TITLE �Q/✓�:df DATE�Z�a-a <br /> --------------------------------------------------------------------------------------- <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 parry 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 fL��1C �'� 61 Address8g; <br /> N/UPS e 1_=__Phone# 7 Gn �ZzZ <br /> D/Z 17J6 e- CoO9 c/2 <br /> i <br />