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WENDT CONSTRUCTION 2OSS479312 .02/2S/04 09:20am P.. 002 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT ' <br /> 304 E WEBER AVE,3P0 FLOOR <br /> STOCKTON,CA 95202 <br /> 'I <br /> y APPLICATION FCR UNDERGROUND TANK RETROFIT,OR P;PING REPAIR P:P-M:T <br /> a <br /> S THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. CO NOT WRIT IN ANY SHADED AREAS.INDICATE PcRM1T TYPE BELCW: <br /> .'i _TANK RETROFIT _P:P;-NG REPAIR/RETROFIT�,UNCER DISPENSER CONTAINNA.ENT REPAIAIRETROFlT _ <br /> i1 f____________________________________________/_y_._____________-__ _ _ _ _ n _.._._.__.____. <br /> I EPA SITE 1 f� �Op (,® l (�' PROJECT COh^.ACT « TELEPHONE e P \ �j �1D 3 <br /> ! ,t 1L <br /> -- ------- ----- °i t - <br /> ---- -------------- <br /> I ! P I FACILITY NAME I PH k <br /> t-•p�+_. _. _ .�Q_ Q.R------------------------ <br /> A --------------- - - 333-_�Q.3g_._.._... <br /> 1 C ! ADDRESS n �� <br /> --------------------------- <br /> ---------------- <br /> L <br /> -------------------------♦---------------L I CROSS STREET <br /> I I r------------- - �l�c� _ J. ....-----------____•________....._ -- - <br /> - <br /> I T I OWNER/OPERATOR I PHO�t <br /> I Y I ren r 1 r'c��,1 _ S n I �3 _1 <br /> I---•----------------- -------- : t - - --. -- - <br /> i ! C I CONTRACTOR NAME I PHONE It <br /> ke,��.d�-__C�rs>ff.1 c_4 - ----- - ----'1:93144----------- -- <br /> I0 ----------------- - ----•---------------- <br /> ! N 1. COWI'RACTOR ADDRESS P.O___eQ?< o. CS L_ S i.__�_CA LIc u ��3�,(j------1_C'_.AS---Pl c'No---H'�'Z <br /> i ! T +----------------`---D--- - - {�{-� <br /> i ! R ( INSURER A,S }c�__�Tr'°-y -----�GL_!_$01Q �h.6� --- -�jGl,�i�, � WOR;C.COt--------- <br /> c <br /> ------C I OTHER INFORMATION ! <br /> tT • - -- - - ------------ *---------- 6....0�`.1�... ....... <br /> 1 0 ( -_--! PRONE C <br /> R --------------•-----------------------•---•-------------------------•----------------+------ ------------------ <br /> I ( I PHONE,Ip <br /> 39 11111-I{Illlllll!i!i':!11!II----------------------------------------------------------------------------------------- <br /> ILII! _ <br /> TANX AD: SIZE I CHEMICALS STOUR CL.'LRr'^.•T i.Y/P �`�-.IIO(7SLY 1 DATE (Iz I2{3� <br /> T 1 39_._^x'A e-)-5 <br /> + /� /� i R�{_C`Gr �ti��Ca ) _ Cj71! Ci!! <br /> !_ <br /> i A I 39 .T — <br /> I N 1 39- I I I <br /> ! K 1 39- i I SS i `�L„IJ.S.�Lv1. <br /> I 139 ! I <br /> ! llfll (I III:; I li'. I.!. llil ! i !!.11 ILII '! -ill - iii T l l i,l <br /> ! P I <br /> 1 L ! APPROVE APPROVED WITH ON(S) DISAPPRO'JE7 <br /> A WI c{ _ONS) <br /> ( N I PLAN REVIEWERSJ����J.. <br /> Iilllllllllllllll!I11 I .I. Illll i I III 11 ;111,i I i , ( II' I'., 7 iAPPLICANT MUST PERFORM A:,L WORK :N ACCORZ1•,:MWLTH SAN J:N COL'.TY CES, STATE LAWS, ATJ RC I ES AIvD REGVLATLO IS OF <br /> SAN JOAQUIN COUNTY, EA'V:RO-1ZNTA-', HEAL'2{ O=7ARTMENT. OWNER OR LICA'+SF, AS SIMZATURE CE32T:FIES THE FOLLOWING, : CERTIFY <br /> ! THAT IN THE PERFORMANCE 01 THE WORK FOR W=:CH THLS PERMIT IS ISSUED, I SHA.L:, NOT EMPLOY ANY PERSON IN SUCH{ A KANN.ER AS TO <br /> BECOME SUBJECT TO WORKER'S :JMPEN>ATICti S OF CALIPOR_NIA.- CON'IP.ACTOR'S HIRING OR S:UBCONTRACC:NG SICNA-URE CERTIFIES 'NC <br /> I FOLLOWING, •I CERTIFY THAT IN THE PE2FCZ"_1-NZE OF THE WORK FOR WliICH THIS PERMIT :S ISSliED, I S2IA:,L EMPLOY PERSONS SUBJEC T <br /> ! WORXER'S COMPENSATION LAWS OF CALIFCIUTA <br /> ! SIGNATURE, TITL �5.� I�AI! I�YU� DATE <br /> I APPLICAN'T'S <br /> ----- <br /> i <br /> BILLING INFORMATION: <br /> i <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payme. <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. prope- <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> j <br /> i Name_ a�,� S Addresses 2� � Ph7� <br /> one # <br /> 0 <br /> Signature C�6G <br /> i <br /> i <br /> I <br /> 1 <br /> EH230038 <br /> i (revised 1/31102) <br /> i <br /> I <br /> I � <br /> ! <br />