|
07/24/2006 12:59 4640138 ENVIRONMENTAL HEALTH PAGE 02
<br /> t i
<br /> SAN JOAQUIN COUNTY
<br /> ENVIRONMENTAL HEALTH DEPARTMENT
<br /> 3D4 E WEBER Ate.3"FLOOR
<br /> STOCKI-ON,CA 95202
<br /> APPLICAMN FOR t RCvROL*V TAW Win.OR PIPING REPAIR REKNIT
<br /> THIS PERMIT EJCPIF<ES 90 DAYS FR171JI THE APPROVAL DATE. Do NOT WRITE IN ANY SHADIM AREAS.MCATE PERMIT TYPE BEI-OW
<br /> TANK RETRom_pw*.G REPAIROMTROFIT UNDER DtveNSER cowAINMENT RrzPAPjRErxWIT
<br /> fi^--- EPA -.Mm -_�..�---- ---t-PROamet CONTACT i TffiSENM # -----'---- ^--------- -- ---- -----_-•- '-+
<br /> --
<br /> .- ----
<br /> l FACILTTY NAME_ _� __ 2 --------- - - - -----
<br /> .
<br /> Pl10pR a• �G�
<br /> CAA + — — —
<br /> C l AODRi `?fit-'. — --
<br /> --__ --------- --I
<br /> � L CA4SB Er1'A.EST �-��1��1L__��.�.c�.•�-�� ...--------"-__-__'•'------�....-----_--..-..-----i
<br /> Pam 0.
<br /> Y _ ei +� �^- _ - �----- -T - +------- - -------- a ----
<br /> _C+-CCXiTR == RN ` C_1 -5rQ✓ V�\ �C �_G` ._� �e>- Psa>�a # - -�L- ---Z _J---
<br /> H l COtTTRAL`tLSR A1fDRS$S`� i1L l� d� ihC�l � Com` Ca LIC # aS 1�_ �S --
<br /> R I INSURER
<br /> -------
<br /> Ai r--------- - ,
<br /> r
<br /> C ' OTM Tutu 1RTIDN '
<br /> -------------------------------------------------------___------------------+------
<br /> T
<br /> "----- PH6pB P
<br /> c ,
<br /> - - -- ---------
<br /> ---'-- ------------- - EK �JRR&WTLY/PR vX0v&LY DATE UST 1115TALLID'
<br /> TANK Yb #I TALAR BITE CKICALS F� T4REb C
<br /> 39- I
<br /> T l 39- t
<br /> A 39- t
<br /> 39-
<br /> ' •'Ii'"Ili"• 'i:l�i l�l,lllil„ ,,,r,r,,.itiiiiii:. 'r iiiiil'i;iii it ..,,r,r. IIS
<br /> l P
<br /> L l , APPR " ' APPRO WITH C7pDITTGafif51 ^- DSSAPF'R6o£D
<br /> l A 1 i A7pACW4EKT WXTH CONDITFOWS1 _'LS—0.6
<br /> N PLAN REK9tlIXIMRS KA �IV. ) PATE' r rrr.r r
<br /> +-^-� .,, „lllt�rrr,,,,lt: ,,,, .Il,.,,,r .1[irrr„ ,.Il,,,r .:il,,,,,, •.,,,rr, •,�'�"„ ,It. :.Ili it.
<br /> APPLICANT W1ST PERFORM!ALL WORK 1N ACCn CE W1TH SA
<br /> TDAOLTTTd CA[7 Y t]CIDINANCea r M= LAW&, AND MES AIS r()BQ ATIDN5 OF
<br /> SAB jC^O Ift COW", EMVTR==TAL HEALTH DEP"TMMT. 00M OR LZC9XSED ACEdT"'S Sx6aMTME CERTIFI1M THE POLinWIM: " CBRTSFY
<br /> THAT Ip TH8 PBRF4HKU= OF TNS WORK PE WHICH THIS PBRKxT ZS ISgOtm. I ,"HALL OX EXPLUY ANY PRUSOM Ila St" A 14A&2=AS TD
<br /> SECO"a 8U8Jt3=TD WORD'S ftHP10=Ti019 LAS OF CALx'FORRZA." CONTRACTOR'9 RIRrma OR SOFIO N"MCrxM SIGMA== C731tTIPYEB T99
<br /> aOLLfNtI1aC: +1' CRRTT,ar THAT IN "M PERa=4"CE O�>�ZM WORK PMW}TtCH TRIS PST ZS X92010, 16IiF1f.L Y F?LOWS SUBST TO
<br /> WOMMR'S COK"WATSON L=-1
<br /> OFxTt '
<br /> .-_ TITLE C��' DA'R'E1R
<br /> •
<br /> APPLICANT'S SIGNXI E:
<br /> l -^-----------^---------^-------- ----------
<br /> +--------------^--------"------ -_-------'----------------------- ^---____ ---_
<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 di'fferent than the permit applicant, e.g. property
<br /> —ar�jt mus�CKnow th resp"ib fer the-b+ ig-by-signature a date below.
<br /> owner,t�p
<br /> Name C • S , -A +4 � Address q! N
<br /> Signature
<br /> EH230038
<br /> (revised 1131102)
<br /> 3,
<br />
|