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,F e 3-19-03; 2:52PM; •925 551 7888 # 2/ 2 <br /> O__W-425/2002 10:09 209468 FIFTH FLOOR PAGE 02 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 904 E WEBER AVE <br /> STOCKTON.CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT.OR PIPING REPAIR PERMIT <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 REPAIR/RETROFIT _UNDER DISPENSER.CONTAINME7•NT REPAIRIRE7ROFIT <br /> �............ ....• <br /> I SITE p -, - <br /> I + -- - .._...-•------ ------- I PROJECT courAcr i TELaPxoNs q Y.hSrL -------------------------- <br /> EPA >C _ Z� �I <br /> y. - �. <br /> J F I FACILITY NAME "- ITIS I PHDidS q (,3C <br /> ! A +--- - �•�-q------------p�p�� ( t <br /> f C I ADDRESS Z �� Wr K('l'�`✓'�L..1f^'tib G� J7:1� _.. ------------------------- <br /> 4., --- -------------------- <br /> ----------- <br /> ----------------- ...__i <br /> ----------- ----------- p'K_ 3� 1 <br /> - `- [,y <br /> I CROSS STREET ^ S-'' t l ------------------------------------- <br /> LI <br /> I I ------------- -----•--- -- ! <br /> - .. <br /> ! 7 � OWNEQLOP8RAT0 (�'� �`�' ^s�:�����/{.�^ •-� __..__.-.------------------•`----------•-----^-_`._..__.. <br /> I Y G I�� a)f�-LZrccA- 1d,V I PFIONE M , I <br /> C I CONrkACTOR NAME �� •M _•.-•--- +-------- <br /> N CONTRACTOR ADDRESS - I CA LIC'- ' <br /> 1 CLASP,--------------•----- <br /> R INSURER <br /> } WORK-COMPAI I <br /> J C I OTKINFORMATION .-.- ----- <br /> ER <br /> I <br /> oj---- - - - - ` ` - - - - - ` ---------•-------------•--- -----i <br /> I R + -- - 1 PHONE q <br /> II -.•-------�--N_---__-_-_-- -'..."--_--_._--__+------------------^...._... -I <br /> PHONE 0 <br /> �- - !I{f111111111111}1(11111IIIIIII -----•------------------------------------------------------------- <br /> ! T 39-1 3�1• .� 4 f T K SIZE I U EMIC74tt <br /> � I C <br /> 0xINSTALLED <br /> A l 39-1136 F I . <br /> X 1 09-- <br /> } 39 } <br /> } 39• <br /> +-p Iltll, I I lllldllll}Illllll;llll ( I fIIII431}11111 x111 I IIi11I111H IIIIIII11111 1111 1 f l I <br /> L APPROVED :�PPP.OVE'A WITH CONDITION(5) DISAPPROVED1 <br /> I R (SEE ATTACHMENT WITH CONDITIONS) 1 <br /> I N PLAN REVIEWERS NAME DATE <br /> -- tff2}IIIt111111HIII 1 tlffllfl{11111!}II}I I Illlilllllllllflll11 1 111113!� I II Illliilil}1111!3 <br /> APPLTCANT MUST PERFORM ALL WORK IN ACCORDANCH WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AM RULES AND RROuLATIONS OF <br /> VI <br /> f SAN 70AQUIN COUTM. ENRONMENTAL Y.EAL-rn L'+£1'aR7MUNT, OWNER OR LICENSED At;ENT'S SIGA7ATURE Cn"'RTIPI£S TRE FOLLOWING °I CEEZTIFY <br /> J THAT IN THE PERFORMANCE OF THE WORX FOR WHTGi TNTS PERMIT IS ISSUED, Y SKALI, NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> J' BECOME SM ECT 20 WORKER'S COMPENSATION LAWS OF CALIFORNIA,' CONTRACTORS XIRING OR SUBCONTRACTING SIGNATURE CERTIFIES Trio' j <br /> FOLLOWING: "I CERTIFY THAT IN THE PERPORhtWCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL• EMPLOY PERSONS SUBJECT TO J <br /> WORKER'S COMPENSATION LAWS OP CALIFORNIA." <br /> i <br /> 9 APPLIGANT•S s1cN.�7uR�: � � [^-c3�!je��I LOU E71."o�r'rFIU •'.I.a_7.c1(3} f(bAT£ � CL- } <br /> J TITLE p I <br /> -------------------------------------------------------------------------- - a -------------------------------------------- <br /> BILLING <br /> ►�-4iA <br /> _____________________________i <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 /> Namur: -R , Address�ti4rL P`IcD��; hone number <br /> Signature-- 71- c� <br /> 3. <br /> >✓Hz�oosa <br /> JAN 25 ' 02 9: 10 2094683433 PAGE -eel <br />