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SAN JOAQUIN COUNTY <br /> �����U����U�� HEALTH DEPARTMENT <br /> ENVIRONMENTAL-- <br /> awswcesnxvs.*"aoon <br /> aroomrow.oAo52o <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT.onPIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES ynDAYS FROM THE APPROVAL DATE, ooNOT WRITE/wANY SHADED AREAS.INDICATE peaw/rTYPE BELOW: <br /> rawxnsrnopn ----p/p�waREPAIR/RETROFIT <br /> -'----_'------------------ <br /> ' - -- | ____-UNDER <br /> _m_ap_s <br /> w_e_cn_o-o-mn^/mwpswrnEpxm�cruopn <br /> ---------------_-----_-----_---_---� _ __, <br /> r�a�� mxmm� uro�p�� w I <br /> �mar� * --------------------- <br /> ----------------------- <br /> F <br /> __________~-----------v | FACILITY NAME [ i0 �«� # n��q 6U <br /> ^� -------'---'-'---'-------'__�.__��_���__ ____'------ - ' ---' -' - -----/|/ <br /> | <br /> � L <br /> | r | ^m»mm" \ �1\-7�� �� ^ L�/�� _f=�_____-'------------------------'| <br /> | z �----------'-----'-'--'--'-���� ` | <br /> | L | CROSS STREET rT A CIII -(10 0 r2j ------ <br /> | � ~' -'--- ~^^^------'------'---- | <br /> mHONE # <br /> | T | OWNER/OPERATOR _L/�� l�, ________|___7'6c�_~_31 -_ 06__] <br /> |-�---------'~-------------' ----- | <br /> | c I CONTRACTOR NAME A ( ____________________�_m«pEw_��bc� _| <br /> 10 ~---------'^^---'-----'---� | <br /> || ' �� ��L -- CLASS------------------------ <br /> T <br /> A- 4-4-7- <br /> N � <br /> | cm�nAoo^^op�o '^---- �---- <br /> r _------�------------'- cu_�_r-o || <br /> w | <br /> | vom�c�» <br /> | <br /> | ^ � INSURER __________________---- ��-_-'----| <br /> ^ |-------------------'-' � | <br /> | <br /> | c | OTHER INFORMATION/ _______________________--__--------------------|z �---------------- | <br /> � PHONE o <br /> | v | ___________________--_---_---_-__--------�----'| <br /> � « ~---------'-------- | <br /> | <br /> PHONE 4 <br /> | | --�-----��-----------��-'| <br /> ||||||||||\U|||||||||||U|||||| --�-----��---------------' <br /> ~-- - cm�zmu� "�o� omm�r�/mu�zm�� | o�o �� �a��n | <br /> | | rm� ro � | TANK SIZE / | <br /> | <br /> | | <br /> | T | 39- <br /> A <br /> 9'A | <br /> | m | <br /> | K | <br /> | | <br /> | | � . <br /> | p || �pmn�o /�e�v�umr� v��,o� :�� DISAPPROVED` |� | --- ��' _ -_' <br /> | ^ | CONDITIONS) DATE | <br /> \ a | PLAN REVIEWERS <br /> | w� �� ��� ���� w� � �� �� ���. �� L�' A� �� � ��� � | <br /> | APPLICANT <br /> ||| <br /> SAN JO^QUINomnT, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER ovLICENSED AGENT'S SIGNATURE cmoIFIo" THE FOLLOWING; <br /> ^z CERTIFY | <br /> THAT <br /> THE <br /> PERFORMANCE OF THE FOR WHICH THIS PERMIT IaISSUED, I SHALI, NOT EMPLOY ANY PERSON zoSUCH um*NNE^ ^sr I <br /> BECOME ��oT" WORKEu'ommPENSATzON LAWS upCALzr"RNz^ ^ cw�*�a', oz�mG � ��"�',.°" o��^"� CERTIFIES THE <br /> FOLLOWING: ^` CERTIFY r�r IN THE ro�.umN� OF THE �� �mWHICH THIS PERMIT IS zooUEo' z ymL^ uwrLO` PERSONS SUBJECT TO WORKER'S <br /> | <br /> cOMpoNS^romLAWS w, cALIFO^NIa.^ | <br /> � <br /> | <br /> TITLE ��n�&�������| <br /> | APPLICANT'S SIGNATURE: ---------��� | <br /> | <br /> -----------------------------------------------------------------------------------___ _-- - ��� -----------` <br /> BILLING |K|FC)RMA7|C)N: <br /> Indicate the responsible party to be billed for additional EHO staff time expended beyond permit payment <br /> coverage per tank, If the par, designated below is different than the permit app|iCa[t, e.g. property oVVner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> t���� <br /> / <br /> �(����� m�� ~ e| '�/ � %L PhoD� <br /> NGme�_�_-�����oor� u ��__���_ <br /> ` .~-. - . '- _ <br /> ----- ����n��' ���� ����� ������� <br /> \ . C��^�' m���� �x� <br />�� <br />