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NOV-14-2003 08 :42 AM DO -.E PUMP CO. 209 537 9398 P. 02 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3RD FLOOR <br /> STOCKTON,CA 96203 <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 REPAIRIRETROFIT UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT <br /> -----------------------­-------------^----------------------------------------------------- <br /> EPA 91TS k ' PROJBCT CONTACT i TELEPHONE P T_•••-•------------------------- <br /> +--------------------`..---------------------- --^^'---- 3./.'1�4 fi3,i 2 f U <br /> �Ir u/ <br /> F ; FACILITY NAME --------' <br /> ,I t"I , <br /> A+----------' <br /> ---------------- ---p---y-M`_'7L ����-------f J <br /> ' C ADDRESS ( lci-. ., _j � ._._ ---------- <br /> I ICROS41REET <br /> T ,_ ,.---------- w ---------^- <br /> - <br /> , __ ---_-- _ <br /> T F <br /> Y I •.J.1�� HON/E�c <br /> , ' i _ 3\ll <br /> 1 <br /> _ . _ <br /> ^..-- - - <br /> - C.tea----f <br /> - <br /> C CONTRACTOR NAMEiUlJ+- -- .___ 7 � -------- --------- t ---- -- ----- <br /> ---' <br /> N CONTRACTOR ADDRESSZS .0 (�, C A c[ASH <br /> T <br /> ' R I INSURER -y------�--/-�^/-^--- <br /> . ; WORX_COMP,N .`f .YJ..JL <br /> �_ � � <br /> C I OTHER INFORMATION <br /> T +-------------------------------------------------------------------------------- ---+--------------- ---- <br /> --------------------1 <br /> 0 PROM; k <br /> R +------------------------------------------------------------ <br /> - <br /> I PHOMF M <br /> I;i;III;IIII;Ill--------------------.____ .--___--____-_-_- _ <br /> i7 � �T 1 1 ____-----I CHEMICALS sTOFFD CURRENTLY/PREVIOUSLY ,______________-__---- <br /> TANK 7D/��p/. �('� ; _ TANK [iI7F IED <br /> 1' 31 C'��BcJ i O�'I .-' DA UST INSTALLED <br /> , <br /> A 1 39- <br /> N 1 39- <br /> 39- <br /> 1 <br /> 4_39_ ...._ ..— _ <br /> +-L �,..• 1,1111„11„11'1'1APPROVED1111_1111APPROVED'WITH'CONDTTI01 DISAPPROVED <br /> _ PROVED <br /> A 1 (5EE �I'�,ACHMFNT WITH CO�IDITTON3) <br /> N PLAN REVIEWERS NAME ✓ / DATEI <br /> +___ <br /> AQPLSCANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS Or <br /> SAN JOAOCITN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICE119ED AGENT'S SIGNATURE CERTIFTFS THE ]FOLLOWING: -I CERTIFY THAT IN THE <br /> PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT I8 199UE0, T SHALL HOT EMPLOY ANY PER.",ON IN SUCH A MANNER AS TO <br /> BECOME RIIHJFCT TO WORKFR'S COMPENSATION LAWS OF CALIPORNTA," CONTRACTOR's HIRING OR SUBCONTRACTING SIGNATURE CERTIE-Ir9 THF. <br /> FOLLOWING! % CERTIFY T'HA'I' IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT I9 TSSUF.D, I SHALL EMPLOY PERSON.,; SUBJECq' '1'U I WORFFCER'S <br /> CUMPENSATTDN TAWS OF CALIFORNIA." <br /> , <br /> , <br /> = � �APPLTCANT's SIGNATURE; 1 ' I•. __ ..__ TITLE � ,L'�- A-9—A - DATE <br /> BILLING INFORMATION: <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_' �, # Address_ Phone# <br /> 2y_ (,LIU qe—,t rte- p_,�ncj <br /> G~,.c$idyl . <br />