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-'10b/18/2005 09:01 2094 Q'3433 EHD • PAGE 02 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEiER AVE,3'I FLOOR <br /> STOCKTON,CA IS202 <br /> APPLICATION FOR UNOERGROVND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> 717E-5 PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY$WED AR[AS.INDICATE PERMIT TYPE BELOW. <br /> _ _^TANK RETROFIT_PIPING REPAIRJRETROFIT _�UNOER DISPENSER CONTAINMENT REPAIR/RCTROFI7 <br /> --------------------- <br /> CPA SITZ 3 ._ '-PRO----•..................... ..... - -- <br /> ---------------- CONTACT I TELEPYONE 1.�! <br /> ► rACILIrT NAME - {W� .p. �_ - - J� <br /> A _ }■, ....._ L..R.1.!'YaC _._._._ --!.P!!!!.. <br /> C AODRESIa.� {l.. __ ll��u? .E� � <br /> L �.CA0_S.; s ACITI� - .-._.--_-_ ._-_--_.__--_---• <br /> T1.. ...r..� - __-_. ------j..-•-_-- <br /> ' C CONTRACTOR wJWR• �Q ,,r -ty�- Q •---•-••1 <br /> 0 • ............... Tt?c3,� -4%s�-; a�•�1� �;• G .NCM[ A 7/1!?_ 6A_ <br /> N : CONTRACTOR AODACSo q� i "' `^'Z �¢ . <br /> A • •-- 1l. ._[_ ! ..fit J� T _CA LIC Y��//1(r_ : CLASS�J <br /> A ZNSIJRISL,�- - _ . ------------------_-------y-`•A-MA� ,/a`nx C .- <br /> l[�II ----ter-- !6 6 Z <br /> C OTNCI 1NFOtxATION - <br /> o ' - - .............................................. ------------------------ <br /> •----•-----••-----. ..------•--..----...-•------------•---------------••-•---•-••-_. rMONC_x__•--------`--•--...----------- <br /> , I...,.... ------ ------ PHONQ I <br /> _ _ <br /> TANK ZO I TANY/vRE'VIOUSLY K SItt ' CHEMICALS STORED CV1tRCNTL .DATE USS IMITALLSO <br /> )f• <br /> I A )f• <br /> x )I- <br /> i„ ... fI.:I::i:i,. <br /> 1 L __ A.PRDV /A.PROV7D WITH CONDITION(s)METH CONDIDltArvaovED 'I" <br /> w PLAte RtVIENSRI NAME " l 14( ►-ITsi ATTACNMW7 TIONiI <br /> • ;:I I I f I;;:l,1;I I,--r n�rt-uiI"rrr� l.T.T _;oArs l,c::;;,t <br /> ♦PPLICAMT HVST PtXrQRM A{L' WORK IW ACCORDANCE NITN IAN JOAQUIN COUNTY ORDIwANCCS, ITATH I w9, AND RULES AND RLCULATlor)I,Op„ <br /> SAN .DAQUIN COVNTY, IHVIAGMHrwTA N¢aLTH DEPARTMENT, --%R OR LICENSED AGLNT'S tICNATVRt C6RTIFISS THE YOLLOHINO: I CFATICY <br /> THAT IN INI PCAPoxsxXCC Or THC w K ►OR MNICN THIS PERMIT is ISSUED, I SMALL NOT ENNrLOY ANY PER60N YN SUCH A MANNER AS TO <br /> DECOMZ SVDJYc2 IO WOArSA'S CONE ATIO„ LAMS Or CALIFOAMIA.• CONTRACTOR'I NIRINO OR SVECONTRACTINc SIOMAHUA MNERCERTIICI THE <br /> caLLCWINc. "I C r■ TYi rurORMANCE Of TM WORK POR WHICH THIS PLRHzT IS IISVCD, I,CHALL DOLOY Pa"ONS ^+UEaaCI to <br /> WOAXER'3 COMPiNIA7 W O/ C <br /> APPLE CANT'L SICNATUR �I.+c r T17L DATE �t <br /> - • - ----------------------------------------- - -----r--•-- ................ . <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 AddressIqLF1Phone # -02.x,5' <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> i <br />