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`04/08/2009 08: 33 289951 STEPHENS-RIVPT ' "T)G PAGE 02 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 Enst Main Street,Stockton,CRllforula 95202 <br /> Telephone- (209)468-3420 Fax, (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> rHl$wiMFR"f EXA R4�5 16t7 t1A OU THE APPROVAL UATt, INtNOr T E PI"AMITTYPF.AI[LOW <br /> — TANK RETROPIT �IpINC RZP IR. ETR61F� U13C REPA,I VRETROFIT COLA 8'TART/EVR UPGRADE <br /> � �� Et'ASlte+a —�� "+ — � Prajoct uortta�ctf.7alRphone# T �R"rf�4--I�S� <br /> G Fmdblt hem, <br /> + Gr,9a 9lrEQ; <br /> Y Clwnat tOsJeretor Phone <br /> C;bntractar Nan^r^ a, - Phone 024q CJ& !� <br /> r Contreatnr Andrese CA Lic M CIE <br /> R �--- --- ~ G.l <br /> Work Comp 019V C 12 6Z. <br /> { -r IC! lRChIllmV m'sName�^-- :xplr�tiOnDaty <br /> ' tCC Inctn lAr'�Nn ra __ Expiretlar.Date <br /> Tank syetem work BrRAL_ a,F�rs�•rt.� �, Data UST <br /> 116WA& D: oank$ize Chemins 5tdnad Vurently <br /> ln91ellocl <br /> A --- <br /> N <br /> I la 7 Approved Approved with conditions _� Disapproved <br /> t~ (9C Attachmant VVltn CondWnn81 <br /> f'18rt Revie"arrs Nal"1 vete / Com' <br /> APPLI 1 nVRJ;VR,{A' Rk W AOJCIfDAMCR WIrH 8AN JCAQUfN COUNTY ORDINANCES,SlAT!LAVA,AM 8.166 AM PROUL+TIQkS of 3AIv <br /> JOAO^JIN COU4TY, 4WRONFAENTAL WLALTH DEPARTNINT,OWNER 04 LICENSFI)AGCNrS QIGNATTVIRE 0tFMl'Il$TH6 FOLLOVWNG 'i CMR11rr THAI)N <br /> 1'k4 P-Z PFT ORMArirp Oc THE WtAX FOR WHICH TH13?YiTSAtT 19;SSldr4,t 6}AALt-NCR t"wi-OY ANY PlRBON IN SUCH A MAPQNI!A AS TQ®eCOiAt 3Q8 MT <br /> Tp W0A'gR'3 CQtit"ENSATIO '4 '3t CCNThAtT0R'8 HIM.J6 dR SUBCONIMACTINO EIQNATUkF(;9RTIPIE9 rit¢OLLOWINO, 'i Cl mmlT 'Y <br /> THAT til T44 P9 W f RUAP HE 4TAX Pop W^I IS P%RMIT 18 ISSUED,I SMALL SMPQY PSRSON$SUBJECT TJ WORKBR'e OMPENZIATICN LAWS <br /> F7gti'IA" /f <br /> °I�"'i 9!^nrls!•a T!t� O 7art� Sf��! dQ j <br /> $iLf.lfvq iNF itMATICI�1: _J �-�-�,•"---�:: <br /> IrldlOate Lie m-vat's ble Party td to hilytd +or eddlt3Qnpl EHD Staff time expenftd t)lyorld ps?rm t paymant ooveretpe per tank. If <br /> the party josigl ated 660yy Ls alfferent Man the pArrnit applicant, *,g. priperty Owner. the party muS! loknrrwl+edgir trria <br /> Nwo-lslbiliiy�fcr_t1,kgbtlting by signature and data below. <br /> M � wITL (�PHt1NE �7I <br /> 1 <br />