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10125/2003 14:46 2094633433 <br />FIFTH FLOOR <br />PAGE 6 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALT" DEPARTMENT <br />3Q4 E WESERAVE, 3FO FLOOR <br />MCKTON, CA 95202 <br />APPLICATION FOR UNDF-RGyROUND TANK RETROFIT, OR PIPING REPAIR PSRMTr � Ar.WR�►'� (� �PAs2, <br />TkIS PERMIT EXPIR=S 90 DAYS FP.OM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW <br />_TANK RETR7=1T_PIPING REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT R8PAIR/R.ET----- <br />---- ----------- <br />------------ <br />----------------------------------- ....--------------------- ----------------- ...------ <br />- ------- <br />- <br />- - <br />EPA SLiE k I PROJECT geaTrscT & TELEPHODIE If <br />I •------------ --- - - -... - - - i PRONE .Y I <br />p I FACILITY >I�MEF2IF'FS-+�%�-'=='--• -----_---....------------------•-'----'_— <br />A►- --•-'- ----- <br />j r I AnDRESS "7400 15, MTCNPg� CANfvTS LVDS s.�Ckt CA��.�._ CA 4 231------------- <br />-- <br />T+----------- ------------------------- <br />L <br />---------------- -- -•- - - <br />L ! CROSS STREET _ _ j - - <br />T+ -0----------------•...------_-..-------.-.-------------------• _ c `- ml�il P1h�=-1� , .....---------1� <br />WNER/OFEMTOR rFGu ' <br />I y S _S. C0UXXry pu�� woRKS _�DRa M` cam? _ _ . _ - - --- .......... -- - ------r <br />' -- +... _ _ - - - - -- 34-7-4-`806 <br />c I cGra:aAc" xA7� BAGI.�j-- Q�SPM + C4TmPP ------------------------ I-!-- # Z��i------- —-----------. <br />I c------------------70 MPt:G�b _� _L� �:. -- --I cA-LIG p---�- �LAss Clol �t� <br />h CONT?Ar-f_R A..DRF.6S G �� <br />I T +------------------- -------------- -- 2°I b <br />R 1 saoaK, cOKF <br />A <br />- ---------------- <br />C <br />- --- - --- <br />-••- --- ti- -- �ll�_-` ----- � 8..--- <br />-11�R ------------..�-- <br />-----------------------J--, <br />I PUMTE <br />._.------------------ <br />- --° --• - - --------------------------- <br />+- 'Illliillillll!IE'I hill „ 1 •---- -...- --....._.. y - - ---- - - <br />I ' eFF+tTCALS STORID CU RWrLY�7REVIOUSLY i DATE V$T INS^.PILLED <br />I 1 TANK ID x I TAWK 622E <br />—I <br />A I 39- <br />N <br />i 34- I 1 <br />+-•-�tlll I I;II!II I Illllii, illli'i illi!i l..i IlllIIT, IIIIIII,.i9{1171, 7''.17 ll!IIIITYTI, tji,i llillii It <br />4 P IT:ON(S) - 3;;6APPROVEP <br />I { <br />L <br />XV -PROVED APPa7 OD <br />I A ATT WI O10I1IZV /( <br />GATE V <br />{ N PF'AN , <br />R IEw"'45DfAMe III{li1!IIIIHIM; <br />---{Illili{IillI WIl ,l: ' <br />I APPLLCAPPI MUST PERFORM ALL WOR2::i9 ACCOi'.DANCE WITY. SAN J0WJ%N ^-DUN7Y ORDINANCES. STATE LASS, )'= RULB^ SAND AE'LT ATIONS OF <br />I p2PARTMMrT. OWNER OR LICENSER AGENT'S S2GN4T-,M2 CERTIFE86 THE POI-LOWTNG: "I L'SRTIF7f <br />SAN JOAQVZAa COUNTY, ETIVEt!ONM3T7'IA:- 1?EALTH <br />'THAT IN THE PCRFORMANCE OF THE WOFY FOR Wh%CR TRIS PERMIT 29 CSSU�, I SR:ALL NOT �LJY ANY PERSON IN S� A MANNER AS TO I <br />I f3ECOYm SUBJECT TO WORT A's COMPLVSAT70N LAMS OF CALIVORNIA." CONTRACTOR'S RIRSDIG OR SLTbC01'TRhCTYN�+ SIGNA' LMM C]MTIP-T'ES 'IPE <br />I roLLOVING, "I CERTIFY TKAT IN THE PERFORnWICE OF THE WCRK FOR WHICH I'KIS PERMIT IS ZS:V=0. I Si{ALL EMPLCY PERSONS y4'3J?Ci TO i <br />wORKER's CGN-P='"xsATTcN LAWS OF CALIFORNIA•" <br />C� I <br />. � 1 <br />TYK'LE <br />i APPLICANT'S SIGNATURE. if! <br />------ ------ <br />F-------------- ------- <br />BILLING 1NFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expanded beyond permit paen' <br />coverage per tank. If the party designated below is different than the; permit applicant, e.g. % p <br />owner, the party must acknowledge this responsibility for the billing by signature and date below. <br />Name Address Phone # <br />Signature, <br />EH230038 <br />(revised V31!02) <br />