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SAN JO,(AQIIIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 310 FLOOR <br />STOCKTON. CA MOM ENVIRONMENT HEAJ <br />FH <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PE?dMfIiIV)IT��'�(�I��,E <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />TANK RETROFIT -_PIPING REPAIRIRt fROFIT ,UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />a- --------------------------------------^ --------. ----------•-•------------------ r------------------- •------- ------------.-s <br />i EPA SLT? 11 1 PROJECT Q=MCr 4 TELSPRDRE N I <br />I------------------------------------- -----------^-----------•-------------•----------------------------------------------- <br />r== <br />----------•------------ -------------------P=CITY :,F¢I- <br />`�? - / I zrnm 4 I <br />ICI_ ��S____________+. <br />_ .__� !___ ____ _ . __._ _ _ j�___.______.. _____-__...I <br />I "----------•-- -------- ------ Y. - <br />I L i.:'>.OSS STREET i <br />iI ---------------------- ------------------------------------------------------------------------------------------------------- <br />T <br />I T I OIa W/OPER=OR I vHODE B I <br />IYI I I <br />I----------------------------------------------------•---------------•--------------..•+-------------- ------------------------- <br />C <br />C ( =n7AGTOR 'Ram � J I ne0's p ® <br />I0 a------------- ----- - ---- - � -Q -------------•-^ -------------,..-------------•• - - � - . <br />H I COrrr ACrM ADDPMS N C[ ASS I <br />I R I L'156Rek I RORY.,COrnp.� ___I <br />IA I-------------- - s5_ _ .,---------..-.------------------ -----------•.- --sa <br />ICI OTHER Ii7n'OMT1021 [ I I <br />IT --------------- -----"------------•------------------.------------------a---------------^ -----------•-----------I <br />101 I PH=P 1 <br />IR---------•-----------------•-------------------------------------------------------«-----------^•-------------•-------------I <br />I I I PRONE a i <br />+-IIIlillllllllllllillililiillllll---------------- •------- -------------'1 <br />I T&IX ID N I TANK SIZE I CIMMICA.LS SIDRED CVkRE?MY/7REVIO05LY I OATS DST INb'TALLED I <br />I 139- <br />T 1 39- I ► I I <br />I A 1 39- <br />I W 1 39- <br />39- <br />39- <br />39- <br />L <br />9 -39_33-39-L I APPROVED APPROVED WITH CDZID=04 (5) � DISAPPROVED I <br />(SES ATTAC HYTFI COND?T2DN8)I <br />I K I PLAN REVZSMS NAFtE DATE I ( <br />*---Ilililllliilllllllilllllllllllililllll IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIilililllllllllllllllllllllillllllllllllllillll <br />I I <br />Kj.Tr mircim ALL PARK nc ACCORDANCE taITH SAN JOAq= C=ory ORDINAL:. mmTE LAWS, Rio R=zG AND RSCJLATYONS OF <br />I M,4.7-0= COUWTY, ENvTRON mtmAL HEALTH DzPART mrr. OnNER OR LICENSED A= -S SIGNATURE CERTIFn a THE FOGLOKING: "I CERTIFY i <br />P=1m;;n"CE OF THE YA7R.0 FOR WHICH T.as PER^IIT IS ISSUED. I SHALL NaT ma MY ANY PERSON iN SUCH A MINER AN TO I <br />ABC;,M SU=C, To 1:YNMIS COMPENSATION LAWS OF CALIFORNYA." CONT'MCPOR'S =3270 OR SUDC0nTAAf,=N0 SIGIIATURE CERTIFIES TRE <br />POI1Z7,QOz ^I CERTIFY MMT IN TSG RERFOPUFM OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY FERROUS SUCJECr zn i <br />CatTeLCATION LAWS OF CALIFORNIA.^ <br />I I <br />i I <br />TLTLE <br />I ADVLIGi27T�E;=SIGNATURG': -- <br />i I <br />*----------------•------------------------------------------------^-------------•-------------------------------------------- <br />•' `' r <br />THAT IN <br />MP. _RIS <br />Indicate the responsible party to be billed for additional EHQ staff: time expended beyond permit payornt <br />coverage per tank. If the party designated below is different than the permit applicant, e.g. property ow er, <br />the party must acknowledge this responsibility for the billing by signature and date below. <br />Name Address Phone # <br />