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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,36°FLOOR <br /> STOCKTON.CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM <br /> THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW. _ <br /> ._TANK RETROFIT�IPING REPAIR/RETROFIT_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT------------------y <br /> IL <br /> 1 EPA SITE i ; PROJECT CONTACT A TELEPHONE R-- 1�Z1E. �N4�_ <br /> ----------------------=----- illi 9 e I <br /> +------------------- HONE R <br /> I i FACILITY NAIL - # __'��_L ______� ___�_; <br /> 1 A + ----------- ____ _ <br /> - 1 —I'9----------------------------------------------- <br /> F <br /> ' C ; ADDRESS I ,,\\-- _ _________________________________ <br /> (��__1_ __ _____ <br /> I L 1 CROSS STREET __ ____________________________________I <br /> c w- - - - --- -- - --- - - -- <br /> r r y owNER/oeERr+TOR � I PHONE t <br /> — <br /> C ; CONTRACTOR NAME C ' PHONE . C* i2r�49_ _______- <br /> 1 o y------------------- yuy'��-�_ _ StO.KaS,. —d'�----------(-�'---------- <br /> --,'q- - <br /> 1 N I CONTRACTOR ADDRESS / _�• -�(_ll�._l_�_VA ________________ CA LIC R__13J J_ ____'CWSS__Jla���1_SL_l <br /> T +---------------------- �.L�.t ) 377 03 <br /> ' NORK.CONP.R <br /> 1 R 1 INSURER - , <br /> I <br /> _______________ <br /> C.1 OTHER INFORMATION _________________� <br /> T +___________________________________________________________________ <br /> _________________+_____________-_________ <br /> I O ; PHONE R I <br /> i PHONE R <br /> r 111111111'r1rr1;11 <br /> ____________________ <br /> I;;I1____________________ ____________--_______-________ <br /> +---11111111' <br /> TANK IDR TANK SIE6 ; CH6[QCALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED <br /> 1 <br /> 39- <br /> T ; 39- <br /> I A 1 39- <br /> N 1 39- <br /> 1 K 1 39- <br /> 1 39- <br /> 1 1 39- <br /> mm:1111 <br /> rrrr, r„ rrr r� <br /> +___111„rr, r„rrrrr�rrrrr,rr rrrrrrrrrrr rrr rr rrr,r rrrrr„rrrr 1111, 111rr.r rrrrrr.11l <br /> APPR VED APPROVED WITH CONDITIW(S) DISAPPROVED <br /> A , D /I /SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS SlI ��•�'� DATE r::: ::1:irrr,i,i,r r r r,r <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND ROLES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONNENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br /> THAT IN THE PEEFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A WANNER AS TO <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.• CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORE FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO ' <br /> WORKER'S COlWENSATION LAWS OF CAAIL,II'FOR/NIA. - 1 I <br /> r <br /> APPLICANT'S SIGNATURE: ,�'(D f d✓V W b' t' r' DATE �lalyy <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> :overage per tank. If the party designated below is different than the permit applicant, e.g. property <br /> )wner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> esu c�Str �x�`�/s —s �ie . 11f <br /> Vame d�bh;t �w Addressjaj-L� 6'-"kv,4. Gc-()4 Phone #9L�k_571-�495� <br /> signature d,7L v <br /> :H230038 u 0 <br /> revised 1/31/02) <br /> 1 <br />