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-SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,10 FLOOR. ' <br /> STOCKTON.Ck=02 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT.OR PIPING REPAIR PERMIT - <br /> THIS PERMIT EXPIRE$60 MAYS FROM THEAPPRO/AL DATE. DO NOT WRITE IN ANY SHADED AREAS INDIOATE PERMIT TYPE BELOW: <br /> _TANK RETROFIT X;PIPING REPAIRA2E(ROFIT•^_UNDER DISPENSER CONTAINMBJT REPAIR/RETROFR <br /> ____—________________________,.-.._._ _-----------—..._..-- <br /> ___________________•_.--------—-------------- <br /> i law 8YT6 N f PROJECT COWTACT S TELEPHwE a I <br /> I + - ----------- ..+_-_._—___- ______—__- -_—_ _—---I _ <br /> I A+ ___ -.,........ <br /> __ __- <br /> ------­----------- <br /> _ ----_-______—q_ <br /> 111 +6 <br /> C I MORSS6 ryI'1$:. Y'Q_(I(, ,� Y'( _T___2—�E__—___1 <br /> 12 + ___ — D.M.Y. L_..xJF <br /> I. L 1 CBO" STREET <br /> 1 T ICIRIFR/OP@BATOR _—....... <br /> I PES a <br /> IFI 11wek.ftV, _ . ' . 1 �4-83.6 -94a-"►— i <br /> I---+-----'--'T ------ -�-•-- -•---------------•----�---- --- <br /> I e coRranccoA�2RnRE 5} _3 $Jr,, I eRQmE P `F.I!F:x -12'`3�q <br /> 1 0 +- ------ Y='. --_'___"Y__✓_' _• '-'"' `5-----_-•-----------___-r•---'-------___-•-- ---v............., . <br /> ! 8 : cON'TRACTOR ADDRESS _ Q SI(A I CA LSC • /,F J lj� l C6aSC$C/.I) ❑�'y f��C <br /> I @ t INSURER ---5 ._ Nl 1t155 �L4YJ 14641 F1?k>¢__ I x-------- <br /> IA I ----_— ' - — - r-------- .- <br /> ' C i oT1@R. IdFORMATiOR - 1 --__ i <br /> i T r-.------------------- <br /> —-----------------------_....- __----__..-..___--__—_-----•----_--- <br /> o I ."__ 1 <br /> I R ---—_______-------------_------------------------- --. <br /> ------'•--sox-_µ_-•__•---- <br /> I I I PRONE It j <br /> +---1111111 It'll it 11-I I I It 1111 It It I I11_--__-..-....,-------------------------—-----------------_----------- ----—-----—----—_-1 <br /> 1 1 TAB[To a I TAN[-SIZE • CLIENICALS GTOREP CPRREIITLY)PRSVIOOGLY ' DATE DST I=TALLPB I <br /> I . i PP. I <br /> T 1IS- <br /> A aP- <br /> trl aS- I " <br /> I G I aP- 7 • t � I <br /> 1 t aP- t <br /> +•••I 11 of II:I U'I til It11� ,1:1;.1:;7t l I .II i J ll:111111 its 1111 Ill l 1171111:it it IIIilillnTMTnTrnT I <br /> P I <br /> L I APPROtlm APPROM RITE CORDYTIWBI 1312"PRNBD <br /> _.AI - IN ATTACHD@ MTN C®IELTIONGI -DATE to- <br /> --till Zb-OS i <br /> 1,8 <br /> PLAA ESVIS "HAIR �f„ Nin <br /> n111n11 ar.t1T,11��.T l I . <br /> :i III Iit I!I III Irn-17;7" 1. <br /> 111 n;T� 11it In1t :Ills I I 1l Olu::I::T�T�r;T <br /> 1 APPLICANT: RUST PERPORN ALL RCRT IN ACCORDANcc NITR 4= COAWzx CGONIY ORDINANCES, STATE LWGI AND RVLES AND RECOWTTONS on j <br /> I CRN JOAQW. I•oVNTY. ENVIRONMENTAL HEALTH DEPARTMENT. OW OR WCNS4W AGENT'S SIWATORR CERTIPSES THE FOLLOWING: •I CERTIFY <br /> SINr IN TVE PERFOtOtAIi C6 OP T. WORK FOR WICH TNTS V.1T IS ISSUED, I'za • NOT MMOY ANY FE w IN SACK A tUrh = AS To 1 <br /> I BECOME GWOECT TO NQRIER'S COMENSATIOR EARS or CALITORSIA.• CONTRACTOR'S MIRING OR SDECCm CTWO SIGNAL E CER'I'J,FLGS TNG <br /> PDLLORINO: •I-CEATIPf THAT 18 TIN: PBRFORNANCE OF TINE MDRt GOR WICKTRIS PERMIT IR xGR@ED, I SHALL SlbLOY PERSONS SORJECT TO i <br /> VORKER Is CO WSATSPI i z t# =I ORMA.• 1 <br /> L SnN1lTntiNiiN ITTINIAMM111 TTtt18 <br /> ?flit i <br /> BILLING MN PRMATION: <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 /> 4S"ia <br /> NamSey- ddress (030 QUivLvt Phone# `keg"a 13 1o03b' <br /> Signature *4 c�' <br /> EH230038 <br /> (revised 1131/02) <br /> 1 <br />