Laserfiche WebLink
0 0 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WESER AVE,3RD 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 54-UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT �''D�OL1 <br /> F ----------------------------------------------------------- <br /> EPA <br /> ______________________ ________PROJ <br /> SPA-ITR # -I -----Cr CON--Cr S TELEPHONE # C3 ID) V79 "q /�/___At le `_ I 'I`��^13 <br /> +___________________________________________ ________-__________ __________ <br /> 0ME <br /> I F I FACILITY -------_/Y(j) ✓"�'VV[J'j�x D�— �11��c <br /> __________ _ _ <br /> I C 1 AwREss _ _ __ I <br /> 11 +---------�� 0 r11.Or#- ---1L-�1_I_�sY_✓_4-- t- <br /> ---------------------------------------------------------I <br /> I L I CROSS STREET ;z eiwd I N <br /> II +--------------- ------------------------------I <br /> I T OhNSR/OPERATOR I FRONS # I <br /> YI <br /> a_P= ------- ------------------------------------------ L1!y� `i!L-------i <br /> I C I CONMAC10R NAH6 <br /> 1 0 +--------------------e+Ccs---------ck_----- t_t-'�5------------------�- <br /> N I OIXPIRACR)R ADDRHSS ,(,� Q' --- <br /> T ---------------------_L_1I R__S�it SN�.L_e_t P -- LIC# (B75 q�0 ___Ia-SA C-1.O+ �-. I <br /> I R I IASD �7 f--_ I <br /> I A I----------S" '-'� I WunK.cam.# <br /> ��"_I-d=---------- 11c <br /> C I dDiBtt INFORWITION <br /> T +------------------------------------------------------------------------------------+---- '-`�-- - �_ <br /> 1 0 1 I FHONE # <br /> ' <br /> I <br /> IR +____________________________________________________________________________________+____________________-___________________1 <br /> I I PNORE # <br /> I I I I I I I I I I I I I I I I I I I I I I I I I I______________________________________________________________________________________________I <br /> I TANK M # I TANK SIZE I CEIIMI S STORED CORR@R'LY/PREVIOUSLY DATE UST INSTALL® <br /> 39- 1 I <br /> I T 139-$7 W✓1 LzAde I , p'q"D C�PrL• AsoYi.vt I I <br /> IA139- I I I I <br /> I N 1 39- M LA ArAdL 1 dfiD q�L • I Aao I <br /> K 1 39- I <br /> 1 139- 12,6E'D 4 A L 1 P'F.-�L.Inx)P I I <br /> I 1 39- <br /> --I I I I I I I I I I I I I I I I I I I I I I I <br /> 9-+ -IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIII�1,FIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII11111111111 <br /> PI A <br /> I L I _APPRRV® _APPROV®WITH IXIIIDITIWIS) _DISAPPROVED If <br /> A ,I 1A ff� 1 ��IO� T�'ACIAffii'r STH NIIDITIONS) �� I <br /> I N PLAN RBVIEWERS NAt�@ 7 (J /J A I <br /> +---IIII m IIIIIIIIIII m it If'TSRIQR` III I 11 1 VIII 1111111111111111111111111111111111111 111IIIII IIIIIIIIIIIIIIIlI1 <br /> I I <br /> 1 APPLICANT MOST P®3FORM ALL WORK M ACCORDANCE WITH SAN JOAQUIN LOONrY ORDINANCES, STATE LAWS, ANO RULES AND REGULATIONS OF I <br /> I SAN JOAQUIN CDUNTY, ENVIRONMRNrn..HEALTH DEPARTMENT. 041NSR OR LICENSED AGSNr'S SIGNATURE CERTIFIES THE FOLIO M: "I C TIFY I TEAT IN THE <br /> PERFORMANCE OF TRE MRIC FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT E Wy ANY PERSON Iii SUCH A MANNER AS TO I <br /> I BECYMfE SOBJSCr TO WORKER'S N ENSATION LAWS OF CALIFORNIA.^ CON TRACROR'S HIRING OR SUEC@TrAACf SI�TURE CERTIFIES THE <br /> 1 FpLx4WING: "I CERTIFY THAT M TRE POEFGRMANCE OF TME WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPUJY PERSONS SUEJECr TO I I WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA.^ <br /> I I <br /> I I <br /> 1 APPLICANT'S----------------------------------------------------------------------------------------------------------------------------------- <br /> SIGNATURe: TITLE "�F3 SJpZf L/i Sr:4La DATE I <br /> I <br /> BILLING I Uer-'QQ��ti A' <br /> . <br /> H°' (�` 1 <br /> �� lam- � •� <br /> Indicate the responsible pbfty to be it d 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_ __Address ______Phone#___ _ <br /> i <br />