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14/10/2005 _ 13: 11 464013B� ENVIRONMENTAL HEH PAGE 02 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 3041;WESER AVE,3"iD FLOOR <br /> STOCKTON.CA 05202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EKPIRES 40 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE SELOw: <br /> TANK RETROFIT jc PIPING REPAIRIRETROFIT_UNDER DISPENSER CONTAINMENT REpX"GTROFIT <br /> r..-_..._______......,...------------------------------------------ - <br /> I --------------------------- ---------------------------- <br /> I EPA SITE II I PRCacr CONTACT 5TELEPHONS (I 1 <br /> A I PACILITY_NAME..M�I� U�© . r `d..••-'------- .............. ........•---__...-I•PHOlI8.1. �r.-,i. ..:J. ��.7...'._•I <br /> veRrss <br /> JL <br /> p-A-------- --�3-- - ---T%/� -- T-------J�-�--=1� ' -C•`=� - 1?'.�. �4-------------------- .............. -------- <br /> LL <br /> I-------STREET ---' ------------------------------'..•--------------------,.----'-`----.._.....__._._...--------------------. I <br /> I T I.OWNERIOPERATOR - FRONS A <br /> i Y + �, ✓a ;�l�_ _ 559ryr3 <br /> CO *.CONTRACTOR DIAME_T e-on---Coo's ' lC_k�FG'`-.e• .......................I FNONE O-$.�J-,�I���tSl�r.. ....... <br /> _ _ --• //� Cy <br /> N I CONTRACTOR ADDRS®6 (PQ l/iL. - � I CA LICA 4. OC) 1 CLAOD A 1-1,4L <br /> T •------------- - `T_� - - - Q �_Ir 1__!t.. _ ��'I-3 ..-.. -- - ----------- ------- '^ - - - ----- . _..-I <br /> ' R I INSVRCR_-_ `-4-•'••.._I�UL'YI��.- _( SS--- JfJ�7 -----.•------------.-• <br /> ------------------------------------ ------- <br /> @'-----,r�(_•� -Q,j•---------I <br /> I C I OTHER INFORMATION I <br /> R -i----------------_--------•---- ------ ----— ---------------------- _----� - ----- -- -- - <br /> -----•---O PHONEA f- - - U�-- <br /> ----------------------• -----•--•--------•-•-------------------•------------i- --' -- --------- <br /> PHONEiI <br /> • -IIIIiIN IIIIlIlI111I111IIIlIIII . ......... <br /> I TANK ID Y TANK SIZE CIEMICAL9 STORED CVAA12frLYJPREVIOUSLY I DATE NST INSTALLED-------------------. .....-----------.---_---•- ---------------------------- I <br /> 13p• � I 1 <br /> T t 39- <br /> A -19 <br /> 9-A139 I I 1 I <br /> >< 139- <br /> {-'-I1ii1 IIID I I11 III lIIII I � I III I III I ILII II I I I I IILI III Illlil 1111 <br /> 1 L I APPROVED APPROVED WITH CONDITION(9) �- DISAPPROVED 1 <br /> AA m ATTACHMPNT WITH LONDITIO1491 I <br /> N PLAN pKvIEWBRa NAN6 l lV(7 DATE <br /> +•^i1I111111ilIIII�tlIIIIIIIIII IIIIrI IIIIIIHII 11 IIIHIIIIIII III 11111 I9 III III I IIIIIIII I I III II II II III11111 <br /> APPLICANT MUST PERVORM ALL WORK IN ACCORDANCE WITH SAN JOAQVIN COUI4TY ORDINANCES, STATE AAW3, AND RVLC9 AMID REGLII.ATIONS of I <br /> @AN JOAgVIN COUNTY, ENVIRONHEMIAI+ HEALTH DEPARTMENT- OWNER OR LECENSED AGENT'S 9tGNATURE CERTIFIES TIIE FOLLOWING: ■I CERTIFY I <br /> THAT IR THE PEIiFORMANCB OF THE WORK FOR WHICH THIS PERMIT 19 ISGU=, I SHALL NOT EMPLOY ANY PERSON IN SVCH A MANNER Aa TO I <br /> BECOME SUBJECT TO WORIUM19 COHVSN9ATION LAWS OF CALIPORNIA.- CONTRACTOR'S HIRING OR 9tMCOw7AACTING SIGNATURE CERTIFIES THE i <br /> FOLLOWING, -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS I89=, I SHALL EMPLOY PERSONS 9UB.IECT TO I <br /> t WORXER'S COMPENSATION LAWS OP IPORNIA.' <br /> I _ <br /> f 1 <br /> APPLICANT'S SIGNATURE' f �l/ Ar{� _ l rt'ufi STILE._oCL ��~�l4'P-'1�DATE I <br /> *-------------------------------------------------------.............-----•----------------------• ----------_...-...-_-.�• _____-♦ <br /> 13ILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit paymen' <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the arty must acknowledge this responsibility for the billing by signature and date below. <br /> Name 61VVI-z'dl A dress -22(a J,),q o t/ hue C Phone <br /> Signatur <br /> EH230038 <br /> .(revised 1131/02) <br />