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10/21/2002 09:24 2094683433 FIFTH FLOOR PAGE 03 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, f" FLOOR STOCKTON, CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: TANK RETROFIT ___PIPING REPAIRIRETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT -------------------------------------------- - ------------------------------------ BPA SITE # - ---- - -- - 1 I ' pROJECT CONTACT & TELEPHONE # �___ ---"-) T PHONE I F I FACILITY NAME(;.L L�-h�L-_l._L_!_I _l-1:�_1-------------------------------- -- C I ADDRESS ----------------------------------------------------- --- --------- i _-I,�( /1-�_- -------^— --- I L I CROSS STREET_________________________i _-_____\________ , T f Ofr N7ER/OPERATOR l 1 ZD ___ ___i_� +--------------r- 61 - - - ----- -------------------- ------- � ---- - I C I CCAI'I7tACIVR NAME �' ' ) � _-_"_--- ,J-- _�1 __'_^ - - -- ----_ --- - --- -- ----� -- N CONTRACTOR ACDRBSS % __ _-_�' !_-„�.(, - ___ --- - ----------------------------- T -- LIC # CSS ___________________ _' 1 ________________� WORK,CONP.# R I INSURER _--_______ A----------------------------------------------------------- C ; OTHER INFORMATION -------------i T +________________________ PHONE # IOI ------------- - --- -i I{ ------------------------------I +---I IIIIIII1111Iillll{lllllilli{ill_________________ I { TANK ID # ( TANK SIZEglra>•.a STOQED CiIRRx/PREVIODSLx { DATE VST' INSTALLED I I I 1 39- I I i i T 39- f I I I A I 39- I i N 39- 39- 39- P 9- I { I I R I I9- I I i I I 1 39- t 139- ��AppROVSD PAPPROVED WITH CCNDITIONIS) DISAPPROVED LI 1 A I i IACNWENT TH CONDITIONS) ' • O N I PLAN REV ams NAME I DATE + Il11f11{Illlli{,IIlI{I IIIIIIIII1111f1111111111 1111 1111! IIIIIII,IIIII;{111111111 i 1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JCAODIN COUNPY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQfIIN CO(ffy, mWIRMOMMI, HEALTH DEPARTMENT. OWNER OR LICENSED AOENT'S SIa)ATUn CERTIFIES THE FOLLOWIN(3: "I CERTIFY I I PERFORMANCE OF THE WORK POR WHICH THIS PERMIT IS ISSUED. I SHALL NOT EMPLOY ANY PERSON IN BL)CH A MANNER AS TO I I BECOME MJECT TO WORXER'S CC'I4PENSATION LAWS OF CALIFORNIA.” CONTRACTOR'S HIRING OR SUBCDNrRACTING SIGNATURE CERTIFIES THE I POLF.AWINO: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR NHICH THIS REMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT' TO I CompsNsATICH LAWS OF CALIFORNI.A.* I I I I W ✓� I APPLICANT'S 6IGNATURE: TITLE I I______________________________._____----+ ---`---- -_ BILLING INFORMATION: VMT IN THE WORHSR'S Indicate the responsible parry to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing key Signature and date below. Address ----------Phone 4N) ScL414C