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10/16/2002 15:48 209468' FIFTH FLOOR PAGE 03 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, ?i FLOOR STOCKTON.CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM TME APPROVAL DATE, DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW; ____TANK RETROFIT ___PIPING REPAIR/RETROFIT __UNDER DISPENSER CONTAJNMENT REPAIR/RETROFIT +--------------------- i I EPA SITE p ---------------`---�-'''•------....._ I PROTECT CO:rTACI k TSLEPHQrjE U L��h - - -- I i----------------------------------- t- ^ - -�iJD.bt•�q�11 I F FACILITY taa.� _ _ --------------- ! A ___ _________j 1 A .---•-------------'0--co----- � I PANE p ��1 8z�- - - - I C I AWES -- - - - -- -- ---------- I I ,----------•----- ��-- S M ((v... T L CTcOss STREET ________________ f i WPV.STKIA_• -- I T I OWV!R/OP'<PAT0.R ',--`-------------------••-----I ">t COa 5 I I PHM p I Y I -* -- --- - •- ----->�_------S a_Lt L-------------- �I---------------------------------- IQ y . 6�•s� IC I CCNIT.ACIGR Pe+co�� -+ -- ----------------------•----------- 10 .-•------------ --•------------- Tic k h O I'HME # ----------- - 3' 5--� - "' •--- --------------•-3I o-b�q-- qq K 1 I N I CONTRACJ'OR A MM33 ( (j "---- --- -------------- v p I G1 LIc p T ------ I�SLI�( � "Ass/� I J ____________ R INSURER I��1+►A I WORx.ox•IP.p -- ---�t� -- - - 46_- t.>n 4 oodb 3s''t I A I--------- --- 0 02 - ----- ---- C I OTHER INPORt�vtTION -------- I I -------------------------------------------------------------------------------------- T0II R -______________________________________________•-_...._____ --- - p + 11111 IIIIIIIIIII1I111111111I111 - I PH4W& II --•--------------------------------------------------------------- I I TAttt ID p 1 T„q,. --------------i SZ"o5 I QL�fICA STORED CMZRFNTLY/PRL'VIOLSLY I PATE UST INST?J LED I T L 37- I I IAI .9 N I 30_ I l x 1 39- I I 1 39- 39- I I - -IIIIIIIIII 1111111111f1111IIII111[fill 1111111111111111111111111111111111111111;111111111f111111111111111111111 R;11111111111111 I i L I AMOVED _APPROVED WITH cmmxTZONCS)`` DIbAPPPAVEp I A 1 dg� (S aoia7f-W CCNDiTIONS) Q �� N I PLAN REVIgNE3s NAME DATE -•-Illlllllllliill�llllllllllllll1111111111 lilllliillll IIIIIIII11111i11111111111111111111111111iillliil Illiilill lillllllllll I APPLICANT MUST PERFORM ALL Marx IN ACCQMWCE WITH SAH JOAQUIN QoMrry ORDINANCE;, STATE Laws, AND RULP:,S' A:ID REGULATIONS OF I SAN JOAQUIN COOn;y, EITVIRaNMENTAL HEALTH DEPARTMENT. OWNER OR LICENs=- AGENT'S SIGLiAIURE CERTIFIES THE FOLZQWING; "I CERTIFY I THAT in THE P�ZFOMWICC OF THE wozx Fat wHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSOtt In 3UCF A KADII•IE_R AS TO i 1 BSJOKZ SUBJECT TO W09r.EF's COMPENSATION LAWS OP CALIFORNIA." =T17R1CIOR'S HIRING OR S M=IRACTIMG SIGNATURE CERTIPIES TE i PCLJAWINC: "I CUTIFY THAT IN THE PERFORMANCE Oe THE WORK FOR.WHICH TY-IS PENT IS ISSUED, I SHALL EMPLOY PERSONS S•,r1174-CT TO WORi=,S COMPENSATION LAWS OF CALIFORNIA," ' I I I I I APPLICANT'S SIGNATURE: TITLE vP DATE 1'0/16 I ------------•------ - - - - - ---• ----- -- - ---- --- - -- --- -- ------ ---- ------------------------------- BILLINV O MA Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. if the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. Name Address Phone# 1