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08/25/2004 12:19 5594855 BANKS & CO. • PAGE 02 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WESER AVE, 3"° FLOOR <br />STOCKTON, CA 95202 <br />APPLICATION POR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 GAYS FROM TH4 APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYPE BELOW; <br />_YANK RETROFITIPI NO REPAIRIRETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />41 ---------------------^^- �--------- <br />EPA SITE 0 ; PRO.IJCT CONTACT a TELEPHONE 0 <br />+------------ __- <br />F FACILITY NANE ' PHONE lir <br />, 1 Lyl' <br />L GROOS 5TREET <br />, <br />T OWVER/OPERATOR <br />PHONE Ik <br />Y <br />---------- <br />- ---------- -- �3P-Z-_`�L------- <br />C toNT�AC=R mm r <br />, <br />s a Co PHONE <br />--- - --------------------------------- -- - <br />w�lo <br />N CQh',{•Rj{CTOR PDDRE•,S e o , CA LIC <br />��za B llh la <br />A INSURE -----R [ �+ �� WORk_tont . it J // / / r•i LZ V -1-0q , <br />�2 SrE' : �l j / C_ /tel J , <br />P. 1--------------- - -----tet,..-^-------`-- ------' <br />I C OTF4R INFORMATION , <br />, <br />T------ ----------------------------------------------------------*-------------------------------------- <br />0 I PHCNE d) , <br />__—_____--„____________________________________________________________„__--_----- <br />PHOn µ <br />TANK ID,N „ „ ---------------------------- <br />, <br />TAN.k SIZE CH&MICALS STORED CURRENTLY/PREVIOUSLY ; MATF U97 INSTALLED ; <br />39- _ <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />, <br />, <br />P <br />APPROVED XAPPROVED WITH CONDITIONIS * pI3gF?RAVED , <br />A -1=Z-&TjFCF=NT KITH CONDITIONS) <br />N PLAN REVIEWERS NAME i�%�.i /✓ DATE 213 C2 jr2q <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH u"AN JOAQUIN COUNTY QRDINPNCE5, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUrV COUNTY, ENVTROIb'NTAL REAL^;R DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFISs 1116 FOLLOWING: "I CERTIFY <br />P>RFO RNCF OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br />BECOME SUBJECT TO WORK'E8'a COMPENSATSCN 'LM43 OF CALIFOMM." CONTRACTOR'S HIRING OR SUBCONTP. CTING SIGNATURE CERT2FIs5 THE <br />rOLLOWLNG! "I CERTIFY TRAT IN rrE PERFOAI-;;NCE OF THE WORK FUR WHICH THIS PERMIT IS ISSUED, T uNALL tMFLOY PBA90119 SUBJECT TO , <br />COMPENSATION LAWS OF CALIFORNIA.” <br />TEAT SN THE <br />WORKER'S <br />APPLICANT'S SIGNATURE: ./l TITL3/I.Y(// DATE <br />, <br />+---- -----------------------------r__-----_ _-_--/ <br />BILLING INFORMATION: <br />� (� ���✓� �wD� (�---��� <br />r f, <br />Z. P"�- )NJ LC�-ld <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 owner, <br />the party must acknowledge this responsibility for the billing by signature and date below. <br />�j / r LL <br />Name I :�,iA) ("o Address X03 E Bv, *arih9x- Ai rj" a Phone # (6-3-7) ` Jor-3Y5'r <br />