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SAN JOAQUIN COUNTY
<br /> ENVIRONMENTAL HEALTH DEPARTMENT JUL 2 8 2004
<br /> 304 E WEBER AVE,3RD FLOOR
<br /> STOCKTON,CA 95202 'ENVIRONMENT HEALTH
<br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT PERMIT/SERVICES
<br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.IN KATE PERMIT TYPE BELOW:
<br /> TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT
<br /> +---------------------------------------------------------------------------------------------------------------------------------+
<br /> EPA SITE # 1 PROJECT CONTACT 6 TELEPHONE #
<br /> Ie�,Tvw+ s�Z•g23 -- 9Z
<br /> i F : FACILITY NAME A r ep '&6 p-o I PHONE #
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<br /> C 1 ADDRESS 1 - I Lz. --SCS l�
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<br /> I L : CROSS STREET H 1_„/- Q 1
<br /> I +-------------------- ---------y! -1
<br /> T OWNER/OPERATOR ; PHONE # ,
<br /> Y 12 VT West Goaaf peljx* , " 41� 1h-sho o
<br /> + ------------------------------ -------------------------------------------- - - +- ---- ---------
<br /> C ; CONTRACTOR NAME --,- 2 '
<br /> 0 +-----------------------T------------ '�"ry CatboY' Fo rGt h c PHONE #
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<br /> N CONTRACTOR ADDRESS �I Lc C - - p� -CA-LIC-#-- ��`L"c--- CLA55A��`
<br /> R 1 INSURER -l WORK.COMP.# —O df
<br /> C ; OTHER INFORMATION
<br /> T +------------------------------------------------------------------------------------+----------------- ----------------------'
<br /> 0 : I PHONE # ,
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<br /> I PHONE # ,
<br /> ------------------------------------------------------------------'----
<br /> TANK ID # �l TANK SIZE C-HEMICA�LS STORED CURRENTLY/PREVIOUSLY DATE U T I TALLED ;
<br /> s I d T
<br /> T 39-
<br /> A 39- I S 1701 14
<br /> N 39-
<br /> K 39-
<br /> 39-
<br /> 39-
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<br /> P 1
<br /> L 1 _APPROVED _.PPROVED WITH CONDITION(3J DISAPPROVED
<br /> A , (SEE ATTACHMENT WITH CONDITIONS) ,
<br /> N PLAN REVIEWERS NAME //�� DATE
<br /> APPLICANT MUST PERFORM ALL WORK 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 THE FOLLOWING: "I CERTIFY , , THAT IN THE
<br /> PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO ,
<br /> , BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.” CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE ,
<br /> , FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S
<br /> COMPENSATION LAWS OF CALIFORNIA." ,
<br /> APPLICANT'S SIGNATURE: TITLE /'^4 DATE Vhk 1
<br /> +---------------------------------------------- -----------------------------------------------------j-----------------------
<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 TL-M f7Q l V W%t;bleAddress Q145' Sly, +- Phone # %2-CV51Y (Z
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