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rA , <br /> • i <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3"D 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 REPAIR/RETROFIT—UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> ------------------------- <br /> ' BPA SITE # _______________________________-__________-_________- <br /> ._ I PROJECT CONTACT G TSLEPMOWB # �� � �- 3(a (�Oi Z-ZZ7 <br /> ------- ------------------ -------------- <br /> F I FACILITY NAME <br /> A PHONE # <br /> -� 2� _ _______________� <br /> +--- ---- <br /> -------- <br /> I C I ADDRESS <br /> I +- --3 <br /> I Z <br /> F?-�-'-, <br /> L CROSS STREET <br /> 1OME------------------------------------------ _- ^- <br /> T OWNER/OPHRATOR ------------- <br /> YPHONE # <br /> --------r--- --------- ---'--'-+--------- <br /> C I CONTRACTOR BANE ` , <br /> o +------- --- �_M- -- TI2� .— Oz CCS T�G.---------PHoxe # \ _ cv - 2Z-; <br /> ---------------- --------- --�- --------- --- <br /> N CONTRACTOR ADDRESS � 1 'g�� .-�. CA LIC # --- <br /> I +-------------------------------------- ----3-- 4'�—'� - ��[?1� <br /> ' R INSURER -- f <br /> �_ _ __T- __ .N\1 �. <�.J;V� ____I WORx.CCNP.# ` <br /> �. <br /> ___________ _ <br /> C OTHER INFORMATION <br /> 1 R <br /> PHONE # <br /> PHONEI--------------------------------------------------------------------------------------------- . <br /> TANK ID # TANK SIZE ; CKM'CAL3 STORED CURRENTLY/PREVIOUSLY DATE VST INSTALLED ; <br /> 39- <br /> 3 39- <br /> A 39- <br /> N 39- <br /> x 39- <br /> 39- <br /> I 39- <br /> i <br /> I.;:.:i. �i.I .r.rrir�.iri r .r.rrr .Ir <br /> L APPROVED 'APPROV3D'WTTMICONDITIOM(S)I"" "DTSAPPROVED;•,.,••,,•, <br /> At^,•w 1/6 (SEB ATTACHNENT WITH CONDIT:ONSI <br /> N N <br /> DArE <br /> �-�`0 <br /> PLAN REVIEWERS NAlII 'V <br /> APPLICANT MIST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN CDVNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS CF <br /> SAN JOAQUIN COUNTY, BNVIROINENTAL RIALTF D6PARTNENT. OMER OR LICENSED A-uENT'S SIGNATURE CBRTIFIH3 THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORNIWCH OF THE WORK FOR WHICR THIS PERMIT I9 ISSUED, I SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACMR'S HIRING OR SUECDNTRACTTNG SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT I9 THE PERFORMANCE OF TAB WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAMS OF CALIFORNIA.' <br /> APPLICAN7.5 SIONATDRH: <br /> TITLE CJ�kT� 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 <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name kUAC�-Ta& z UvAddress C�k�2>5—�NPhone# \c) z7XZ7 <br /> Ca :5jUZC4 I <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br /> 6 'd - G296*2629S H331MOBHUO WH10 :6 9002 TZ qa3 <br />