Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE.3"0 FCC OR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR U41DERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 9C DAYS FROM THE APPROVAL DATE. 00 NOT WRITE W ANY SHADED AREAS INDICATE PERM:T TYPE BELOW: <br /> TANK RE-ROFIi PIP)NG REPAIR/RETROFIT UNDER DISPENSER GONTANMEVT REPAIR/RETROFIT <br /> ._. ------------------ ---------------------------------------- ----------------- --- <br /> BPA SITE 0 ; PRDJ-jt--* CCWZACT i 1=3PRDNFi 4 11 <br /> h________________________ ________----__________.-__--________________________---____-_ _ ________________---- <br /> I Y FACILITY NMIZ ; �. ",' �.. 2©`7�- PHDHE # T� 3(� h (140 <br /> L :CROSS STROCl �✓.�--1-c� ----- <br /> i = <br /> ----------------- ---_--__-________________r-_------------------------rN__________. ---------------------- <br /> T i OWSR!OPERATOR P1i02i6 0 <br /> z �Z Gni `-- -- 1 - <br /> C OOMRACTORMws _ � rt' .' t -t--a�- - �--_------------------------------------------ <br /> ------------- <br /> -----Cafflifth -- - - - ---- Ch-LIC -7�SCLAW AMR - -------- Gc <br /> _Lp - = � <br /> ---- --- P— -----+---------- k z�1�IS2 <br /> C <br /> 01M IAPOIOIATIQI <br /> _ -----.__---'------`--"------------------ .------------------------------ ------------------------ ------ <br /> O : ~ PONE IF <br /> F' �-------------------^-------------------------------------.-------— -- - <br /> PRO" 0 <br /> +�-.� • .:� "••::••••• ��..... _-____-___--_________- ._ --------------------- .-____-_____--__-___---- <br /> 1 TA'hI IDS# TANK SIZE CRW--CAL9 STWUM CURRWn'..Y/PRSVIODSLY I DRT8 RST INSTALLRIO <br /> S 39- 'C",7 L.)t. -...,,,.. <br /> A 39- _... 70 7 (-1 L <br /> N 39- <br /> K -- <br /> 39- - <br /> 39- _ <br /> L- ,• r' .' ••'••,.•. •;.APPROVM APPRDVM MTTN•C'OFIDITIOLS(S)I ,,.'.__•DISAPPAOViO:.•. •'I••'••:t: , <br /> i A : t�(Y& SHA AT7ACFM Wr VI78 CONDITZOWS) ^ ^ O J <br /> II : PLAN RSVI%WARS NAME I(� ' 1IRTS 1 1 tv <br /> APEl.Ycmn mj!xT nit"H ALL 910BX its; ACCGRIIANCI: MTT4 SA,N JOAOUIN CDWTY 0ADZIIAVCR6. STATE LAMS, AND RULMS AND RicuuIATTONS OP <br /> SA,> JOAQUIN COMM, 3SVIROURESTAL IIP'.ALTV OEPARTMR9T. OSANZA OR LICENS60 A3ENT'S SIONAT'JRS MRTIFIE5 Trig PO::WWING: -I CIRTTFY <br /> ;4A"I <br /> IF TRS PERFUACWC9 OF TIW MORA FOR WMrR THIS PERMIT 13 :SSLIED. : SNALL NOT LTIPLCY .'UCY PET.&DN' IN SL:Lll A 4A". M AS TC <br /> B--CN3 SUBJECT TC MORK3R'S COMPROSAT-ON :.AKS OF CALIFORWA.• LOGTRA.'-.^JR'S ill-RING OR SL1ICCkN-RA''-TTNC KIG9ATLTL1 CERT-FLES TRE <br /> FOLLCMINC:: CEXTI FY THAT Iii This K4OR <br /> PERFCRNCE CF rXE MK FOR GR".CK THIS PTRMIT IS TSSUE*,1, : SI-:A?L BM ,PIDY PERSONS SLWFC:T ?'0 <br /> GOR ALBB <br /> +R'S CJMPSATI0K LAOS CF' CA'.:FORMIA.' <br /> APDLICM'7'S SIGNATLTRIi- _., - TITLE ,��ti1Z! tiRTE j3y� <br /> .__._____-_---________...___________ <br /> BILLING INFORMATION.- <br /> Indicate <br /> NFORMATION:Indicate the responsible party to be billed for additional EHO 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 /> Name�UA V?Tu�Lt-fgt jiz, 'Address Phone# <br /> Signature �-- <br /> E H230038 <br /> (revised 1/31/02) <br /> 1 <br />