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.-SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304E WEBER AVE 3RD FLOOR . <br />STOCKTON. CA 9.,`202 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT. OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRE$ 90 DAYS FROM THE APPROVAL DATE, DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE 3ELOW: <br />_TANK RETROFIT PIPING R6f'AIRIRETROFIT _UNCER DISPENSER CONTAINMENT REPAIRIRETROFIT <br />+-- --.^--------------------------------- -----------------------.._------------------------------------------------ <br />i -UPA <br />-------------------------------------------+;•PPA SITE I PROJECT _C Cf <br />& TELEPHONE 0 d j 1 <br />Ai.FACILITY NAME- V ,'- --- ---------------------- ---'-- •------------_PHONE-fY p - {- �� �-x'31-I-.------I <br />{ C 1 A-VORESfi .. <br />1 _+=---------=--!R4-----.1.�----==-=='''_ru-c------------------- -- �1k^--------------------------------- <br />�- <br />�S <br />{. L 1 CROSS STREET (} %l. ' <br />i I ---------------- - -T --------- .•___-___--__-..,.--..------------------------------------------------------------- <br />-----------------"-------------- <br />! T { OWIPifR/d@6RATOA i PHONE#� p (s c,? <br />vt <br />-= V- - .-----------------•-----*--------- <br />C <br />---- - 0 1R 0-------- <br />-+- ------t• .. - <br />C 1 CONTRACTOR' NAME S t -S 1 PHONP iI� �{-• ��-� , . <br />0 +---------=-----------------------------=�------------------------------------------------------------------- <br />' N 1 CONTRACTOR ADDRESS j ('yF ! ' /� `,�/' p �1n. T 1 <br />� _ _,, j_ �35� _ --- -.. CA IBC&-'?�-1--------___1_tLyAS5��lilQl•il �'iV���1a`t R"lG <br />A + ;NsvR6R ��9- I [li�tlt_!�® .::- 5 1 ....... ........ ----------- ----------- <br />-- / TOj-4-' o mZ ^- —i <br />1 C i -OTHER INFORMATION <br />1 T ."------ -'------------------------------------ ^---------------------------------- --------------------- ^------------- -.......... <br />1 <br />7 0 i i PRONE 4 i <br />' R *-------------------•---- ---=-----------^--------------- -------.-.---*------ <br />_------ ------- ....... <br />r i <br />I PHONE $ <br />+••-;11lIIIi111111111IIIIIIIIIIIIIII-------- <br />1 TANX ID q %-INR 6ISE CHEMICALS STORVP COUR=TLY/PRSVIOU&LY 1 DATE UST INSTALLED <br />T i 39- <br />I A139- <br />K 39• ' <br />�"'--III{ir...ri rill', {ilii{rr{{i {ii:l11 !1111{{iii � <br />1 A I 1 <br />1 L 1 _ ARPROVED 'APPROVLD WITH CO3MtTI01d(S) DISPROVED i <br />I.A 1 (USS ATTACHMENT WITH CONDITIONS)�l 1 <br />N PLAN PEYIEWBIRS N. W _AN DATE V.• LU -O 1 <br />'i11 <br />.I' •i• ilriri{ rill{ii {i1 1{{ii !ilii ii IIr{i !i !. i1{iii i{iii <br />i <br />"PLT=T MUST. PERFORM ALL WCRK IIC ACCORDANCE WITX BAN C'OAQUIN COUNTY =;;NANC=, STATE LAWS, ANO RULES AND REGULATIONS OF 1 <br />SAN JOAQUIN 9000TY,29VIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOIS.OWING: "I CERTIFY <br />THAT LN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL Not EMPLOY ANY PEnCE4 IN SUCH A MANNER AS TO <br />BECOME SOBJPCT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES T99 1 <br />POLLOWING: "I'MTIFY THAT IN =2 PERFORMANCE OF THF WORK FOR WHICH THIS PERMIT Is IS&UED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WORIC;R'S COMPENSATION LAWS OS CALIFORNIA." { <br />i <br />1. innTTn111MIn nrnrtnmrm21 T'fIM <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 />1-1 <br />NamesmtL( G v1S43 ddress (030 allivtO Phone# -{o --x-13. 03S' <br />re <br />Signatu <br />EH230038 <br />(revised 1131102) <br />