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05/24/200E 08: 39 2094683433 EHD PAGE 03 <br /> s- <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL. HEALTH DEPARTMENT <br /> 5O6 E WESER AVE•3^ FLOOR <br /> STOCKTDN,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> TTH5 PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SNADED AREAS.INDICATE PERMIT TYPE BELOW. <br /> _TANK RETROFIT_PIPING REPAIRIRETROFIT_UNDER DISPENSER CONTAINMENT REPAIR/RETROFM <br /> +—-----------------—___________.v_________________________—____—__—______—_—_—________-_----_______--____—_____--____+ <br /> ' I i EPA SITE $1 <br /> I Ai PROJECT CONTACT & TELPHONS C <br /> +------------------------------------------------------------------1111---_- <br /> _ <br /> s I rncILY vaN � r 4 jI -R-x <br /> +_______ — ___________ — PUON-----111-+p-----.----Y-11'-11/----11-11�---(J-1-=�7- <br /> -----7--/a--Z----o---- <br /> - <br /> - <br /> S <br /> I C I =E_- L <br /> I I +------- ______-_-_ <br /> -_11111111-____1111 11_11--1111-----1111--- <br /> i I <br /> L CROSS STRIU:T /���/ _ --«___--__-----«-_---- -_-________----------------------------I I + ---211-0------- 2 .270- �/8 <br /> I T L OWNER/DPEltATY1R I PROM <br /> Irl i, Cc r, -3 <br /> - +--------��------------------_./_ ---------------------------------------------�-1111---�------------------------------ <br /> I G I --------- -----7 /�L% d/✓2o/Y1 `yllk! «-��N�------- � - --�------- <br /> Olt <br /> 013 <br /> I C I CONTRACTC1 M- <br /> I N I NNSAACT- ADDRESS ��.j-] �7�/Tim/ S/" s-___I CA LIC P &•73 g 7/ Oi,xSS e a HZ; <br /> K�--------- - 1111 1111 --1 - — - --,----------------- ---------- ------- <br /> R I INSURER S%A_ N� WORR.00NP.#I-- - - 1 — 1111--1111 - - 1111 - 1111- ---------- 1_S $_ izz-Q- <br /> C 1 OTHER INFORMATION <br /> O I I PHONE K <br /> I - I PRONE { <br /> ---—_—----------------—----- -------------------------------—_-__ __ - ------- __ <br /> "RNR ID-# TANK SIZE I CBEMICALB PTOAEC CO" MMY/rImIOOSLY I•DAffi-UST =STALL <br /> 139- <br /> T r 39- <br /> I A I 39- <br /> I N 1 39- <br /> IRI39 I <br /> ILII .III IIII:I I:IIII IIIIII' illill H lit lr r..... r �.�....... <br /> ,,,...r... ..y III .Y. I <br /> "'"'IL`IIII ': IiI1i' ..r r..r.,.... „r. <br /> rrr,�.nrrll <br /> I P I I <br /> I L iAPR .APPA NITH COODTTICN(S DISAPPROVED I <br /> L A I 1 "C WITR CONDITIONS] I <br /> I N I PIAN REVIIR!°_RS N� DAIS J <br /> ..„................................ ............. <br /> I; <br /> APPLICANT NOIR' PERFORM ALL WORK IN ACCORDANCE WITH NAN JOAQUW COUNTY OROINANCES. STATS LAWS, AND ROLES AND ARGUSATIONS OP <br /> SAN JOAOUIN 1100ftlf, £NVTROIO]=AL RBALTR 152PAMIRRT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES TWE POMOWING: 'I CERTIFY i <br /> THAT IN THE RSRFORKhNCE OF TIP WORK FOR WNICA MIS PERMIT IS I58USD, 18HALL NOT WPWX AA'Y P Cff IN NOCK A MANNER AS TO <br /> BEGONE £II8JI1,'I TO NORKER'E COMPENSATION IANA OP =XVORNIA.' CONTRACTOR'S HIRING OR SOHC'ONTRACTING SIGNATURE CERTIFIES THE <br /> FOLIDWING: ':: CERTIFY THAT IN TRE PERFORUMCE OF TRE WORK FOR WHICS THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORASR.'S COMPENSATION LAWS OF CALIFORNIA.- / 1..rt <br /> APPLICANT'S !;IGNATURS: � � y,/�/� TILL£ 4 /NAF-CKI d4 DATE -G61 <br /> ¢------------------------------—-------------------------------------------------------------------------7--------___-BILLING. INF=ORMATION:.- <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 <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name _K1,4,/CT4-o,-- Address 7317 /d 1!//Mi p A /3�eeibU�Phone # - U-7o2o <br /> Signature__ <br /> EH230038 <br /> (revised 1/31/02) <br /> i <br />