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117 Jul LV VY 11.JJ LV JYVVJYJJ i 11 111 1 t-VVI\ 1 r-IVL Ulf <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,311E 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 REPAIRIRETROFIT UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT <br /> ------------------------•--------------------------------------------• <br /> I ( EPA SITE # ------------------------------ <br /> --------------------- <br /> I PROJECT CONTACT TELEPHONE # -- - --+ <br /> I +----------------1�- ---- ---------------- I <br /> t F I FACILITY NAME /' r PHONZ # ------�---� <br /> 1 <br /> C { ADDRESS g---------------- •- •---- ------------------------------------------------------------ <br /> 1i <br /> g <br /> �v <br /> L I CROSS STR$ST --- 1 <br /> 1{II-YI--+.I------------------------------------------ - --------i- •_-c--�-�--c- <br /> T OWNER/OPERATOR � PHONE # <br /> - __ - ------ -----------_ �- ==�-----^-•--iI1 <br /> �$3-- <br /> I C { CONTRACTOR NAME PHONs # <br /> I0 +----------------- ?/ /. .--- -- --U- -- `-------------------------- <br /> { N 1 CONTRACTOR ADDRS9S 2fl}`LI ------ ------AL <br /> R I INSURER I WORK.COMP.# <br /> A ---------- ------------- ------------ --•-----' <br /> C I OTHER INFORMATION I <br /> T ------ <br /> I r ----------------- -•------ ------------ t <br /> 0 ------ PRO=-# <br /> II -----------•---------- -------------------------------1 1 I PHONE # 1 <br /> 1 1 <br /> +---illi{III{III1111111111111111IIII----------------------------------------------_-------------------'.--•._..------------•----I <br /> I 39- T # i T SIZE i CH!E /,R SHRED CURRENTLY/PREVIOUSLY i VA T INSTAL=D <br /> I 1 <br /> I T { 39-A 39 <br /> 1 <br /> IN139- I 1 I 1 <br /> l X 139- <br /> 1 1 39- 1 I 1 I <br /> +---1111! 1 IIIlIII111111t1111 111111111111 1III 1 1111111 1 IIIII'Iltilllli111111111111111111111 1 1 1 11111111 <br /> L I PP APPROVED WISH CONDITION(��C AISRFFROV I <br /> I A I (S A ACHMENT WITH CONDITI ) <br /> I N ( PLAN REVIEWE" NAM£ DATE <br /> 4- 11111111111111111111{ 11 I I 1 111 III t 11111 I 1111 11 11,1 1 111;11 11 ITIT (17 11!111-II{IIIIIIII <br /> APPLICANT MUST PERPORM " NORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND RE( ATIOXS OF I <br /> SAN JOAQUIN,COUNTY, ENVIRONMENTAL HEALTH DEPARTMWT. OWNER OR LICENSED AGENT-S SIGNATURE CERTIFIES THE FOLLOItID4- "I CERTIFY I <br /> THAT IN = -PERFORMANCE OF THE WORK FOR WHICH TEIS•PERMIT IS ISSUED, I SHALL NOT M*XoOY AdY PERSON IN SUCH A MANNER AS TO 1 <br /> { HECOM SpB.lL'CT TO WORKER'S COMPENSATION LAWS OF CAL;FOMIA-" CONTRACTOR'S ELIR,INC OR SUBCONTRACTING SIGNATURE CERTIFIES THE 1 <br /> 1 rOLTAWING; •I CERTIFY THAT IN TY3:; PERFO OF TRE NORK FOR WHICH TRIS PERMIT 15 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> { WORKER'S COMPENSATION LAWS OP CALIFORNI1 <br /> 1 1 <br /> 1 <br /> 1 <br /> APPLICANT'S SIGNATYX$= TITLE - nxro <br /> { I <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 <br /> owner,the party must acknowledge this responsibility for the billing by ssi.-gnaature and date below. <br /> Name Address ' ) 9V U� Phone# <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 - <br />