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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3� 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 REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />-___I________________________________ _--------- <br />--- <br />___- <br />EPA SITE # PImJECf CONTACf 6 TELEPNONE # 1kIx`6 /LLJ Jam' <br />----------- L'n+1J_OvO03.2Y.�6 /�%N+ �f9� f9�2 II <br />F I FACILITY NAME f���/ //f //�/z/�.s� FHONE # <br />I C I ADDEEsS <br />1 z__Ai�S/fi1 ----------- Iuar4"_----------------------- <br />L I <br />I CFOSS STREBI / <br />Iy______________ ___!_/ -------------------------------------------------------- -------------- <br />1 <br />1 T 1 ONNIWOPERNWR ,/ r RHONE # <br />Y Ile- lEr/£ i/i.✓n/64i 9/3-aI/I/-36 /S 1 <br />Q--�----------------------------------------------------------------------1 <br />O 1 CYR]TPACIOR NAME19m2ra✓�l_4--(/E�✓!il_..6✓L1L(LtL./E,� /-------�f�1�-----NONE # ti6a •.i-%---39%-- <br />T s CON7RACIOR ADDRESS , /�`O`� ------_---- LIC _#__ //_/_Q ___ _�SS___'C�__ d5�____ <br />A --�---lJ�v%/ �l/�Y�/�yL/q_(�/�/A//_l9_!_/73----- w°" `°"�_"__las%6_/1t�._2_lZ <br />C OME----t I ------TION___ � ---___ L///{___LO /_Y_/__/_/__I� r <br />4f L(L <br />r D �v%10---------�fj1� L %�O'% %1- /2---------- - <br />n n u l n n l l l l n l u 1111 n n-- ----- -------------------------- <br />TANK ID # TANK SIZE Y DATE U T IN�rALLED <br />1 139- <br />T <br />39- �D; DDil IYO,yOE�!/.GGIn/' x/96 -1 <br />A 1 39- _ <br />1 N 1 39- <br />i E 1 39- <br />39- <br />1 139- 1 <br />--- 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 1111111111111111111111111111111111 <br />P <br />L 1 APPROVED APPROVED WITCO CtlNOITION(S) DISAPPROVED <br />A I (SEE ATTACHMENT WITH CONDITIONS) <br />1 N PLAN REVIEWERS NAME DATE <br />' ---1 1 1 1! 111!111!111111 11111,,,11111111111H111 II I I II11111111111.....����111111111111 <br />APPLICANT MUST PERFORM ALL WORE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES TBE FUIZONING: "I CERTIFY r <br />PERFORMANCE OF THE NORE FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT ENIPLJY ANY PERSON IN SUCH A MNINER AS TO <br />1 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CVNTRACNR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING: "I CERTIFY THAT IN THE PERFOR CE OF THE WORE FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO r <br />C ENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: TITLE (�- /gip �(//6L DATE XOS <br />______-___.____________________________________________________________________________________________________________________. <br />BILLING INFORMATION: <br />THAT IN TILE <br />WORXER'S <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 9-aAddress dy'o (�irrr.j S Phone #�`rd u? 17 <br />