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SAN jOAQU1N COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 904 E WEBER AVE,3F10 FLOOR <br /> STOCKTON.CA 95292 <br /> APPUCATI N FOR LRVoERGROUND TANK RETROFIT,OR PIPING.,REPAIR PERMIT <br /> INDICA- Tr;$IiADEO AREA <br /> THIS PERMIT EXPIRES 00 DAYS FROM TME APPROVAL DATE. DO NOT VYRiTE IN ANY $. CE PERMIT TYPE BELOW: <br /> TAPIK RETROFIT—Ye1PING REPAIRIRETROM PNtIER QISPENSER CONTAINMENT REPAIRiRE------- <br /> -----'------ ----- <br /> ACP 6' TELEPHONE # <br /> +-----•----'---------------- { PROJECT COtix --------...-----------•- -- <br /> II EPA SITE # -"-------- -----------------p-----------"----- I PgONE # -� Z -_S� p- { <br /> 8 <br /> -------------------------------------- <br /> -FACILITY NA14F --- ---- - _ .r-J& -3 <br /> �Z- -------- i <br /> -- - <br /> c i AwDREss ._S_ ._ <br /> _--- <br /> L I CROSS STKE _ S ----- -----' 1 PRONE # I <br /> T I O /OPERATOR _----------I <br /> _ _?( -----------------+---------- - I <br /> c I coecr>zACrOR etA"r� :_--�l �yry - - �l�sl'ZL� - --- = 5---�-��--_ -- = - -i <br /> o --.-------- ------ <br /> T +-------------------- I wcc.coam-# <br /> jR { INSURER ---------'-------------+------------ I <br /> A I----�_...----.... <br /> ------------------------- <br /> 1 c 1 OTeER INFORM7iTxaN - •----------� <br /> I -------------- PRONE III <br /> -•--------- <br /> PHONE 0 <br /> _.----------------------------------------------------------- <br /> ---- '�iICAi.B---- <br /> +---IIIIIIIIIIIl�IznIIRIIIIIII1Ill�---"-----TSR SIZE --- { STORED CURRP,NTLY/PRst10U$LY OATS VST ZNSTALLF.D <br /> T� ' <br /> 1 <br /> I 139- I { <br /> I T I 39- ! I I <br /> 39as-' <br /> { N <br /> K 39- <br /> 139 i, ITM=77717111i I <br /> I 39- { I ( I <br /> DISAPPROVED <br /> P { APPROV 0 APPROM WIT!{ CdZIDIT�ON LS) �- <br /> L I (SEE ATTAc;wnE7T WITK CONDITIONS) DATE <br /> A <br /> I IIII� 7II <br /> N I ft" REVIEWS*$ I11 <br /> +---UIIII11II1111IIIIIII 1 I .II ill VII II 11 IIIIII I I <br /> I STATE LAWS, Am RULES AND REGULATIONS OF <br /> I APPLICANT MUST VSAPORM,ALL WORK IN.ACCORDIWCE FfITfi $Alf JOAQUIN COIRITY ORDII�fANCES, _ CERTIfIES <br /> { SAN JOAQUIN COtIIdTY, ENVIRONMENTAL - ' pARTMENT_ OWNER OR LICENSED HAj,XAGEIpr,NOTI ANY PERSON �S H A KANNER•AS TO <br /> TIPY I <br /> I FXRS THE <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TE16 PERMIT IS ISSUED, <br /> BECOME SUWECT TO'NORRER'9 COMPENSATIad�WS OF �IWORK P, CF. TTOR'S HIR RIKXT IS 34 UID II $HALL EMPLOY pMZSONSTZ9U9Jfi T TO <br /> { FOLLQWXXG: "I CERTYFY THAT IN THE <br /> { WORKF.$f S C13MPENSAT2Oli LAWS OF FORNI <br /> 1 <br /> ,r I <br /> TITLE J Sl.�i✓ DATE <br /> ApPLICAA7T'8 $i(#SATURE: ----------------- -------- --------------------------- <br /> -:--- --* <br /> ----------- --------- <br /> -- <br /> BILLING INFORMATION: <br /> rty to be billed for ad <br /> Indicate the responsible pa EHD staff time expended beyond permit paymel <br /> average per tank. !f the party designated below is different than the permit applicant, e.g. propert <br /> owner, the party must ack wiedge is responsibility for the billing by signature and date below. <br /> "�'✓ 1 v � 6 Phone#P 09 8 ` z 5 � <br /> Nam C� u Address .3640 �' ` <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> z - <br /> Z0 MVA HI-IV3H -IViN34408T W3 BElov9v ST:9T 90OZ/EZ/60 <br />