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Jul 07 06 09: 49a Jeffrey C. Henley 714-739- 1499 P. 19
<br /> SAN JOAQUIN COUNTY
<br /> ENVIRONMENTAL HEALTH DEPARTMENT
<br /> 304 E WEBER AVE.3"D FLOOR
<br /> STTOCKTON,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 REPAIRIRETROFIT _UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT --- - -+
<br /> - --------------------------------------------------------
<br /> +----- -------- ; PROJECT CONTACT 6 TELEPHONE #
<br /> 1 EPA SITE # __________________________________
<br /> ��•r- � � _______
<br /> -------------------------------------------- PHONE #___
<br /> F ) FACILITY NAME -A.IZw r�-•(„/ ! �----- ---- - -------
<br /> ,
<br /> � -----'---
<br /> C ADDRESS f!
<br /> -Y-- - --- �-----
<br /> --"--------------
<br /> Isr ---- ` -------------------
<br /> L
<br /> ----------------L CROSS STREET----------------------------------------------------------------------------------- -------
<br /> I ------------
<br /> -
<br /> PHONE # '
<br /> T OWNER/OPERATOR js.— '
<br /> ------------------
<br /> - -+---'--------------- PHONE #
<br /> C i CONTRACTOR NAME _�1� Q- --�--'� Cfr --------
<br /> O F______________________ __ CP. LIC # CLASS
<br /> N I CONTRACTOR ADDRESS MI�'�1_�.►• �`!r_ ?4"-1_TIES--- t ,/ (C_}wr..
<br /> ---4c -CQ _ l_3
<br /> T +------------------ WORK.COMP.# , S�t�-\_SQ-= C.1C'TT,
<br /> R , INSURER Ste. t•,k? _ - NO________________+_________________ _
<br /> ,
<br /> C OTHER INFORMATION ___________+__________________________________
<br /> ' T +-------`------------------------------ PHONE # '
<br /> ' O '
<br /> R
<br /> -------------------------------------------- :_PHONE_#
<br /> ------------------------------
<br /> ------------------ ' CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED
<br /> TANK ID # TANK SIZE
<br /> 39-
<br /> T 39-
<br /> A 39-
<br /> N 39-
<br /> K 39-
<br /> 39-
<br /> 39-
<br /> I
<br /> 9-
<br /> 39-
<br /> 39 ......, ,,. .
<br /> PAPPROVED WITH CONDITION(S)
<br /> DISAPPROVED
<br /> L APPROVED
<br /> A : L ATTACHMENT WITH CONDITIONS) i-ky-0,6
<br /> DATE V
<br /> N PLAN REVIEWERS NAME ,.,�,,,,,,,,,,,,, ,, �,,,� „ � ,r„� ,,,, i „i,, ,,,, , ,,,.
<br /> .... ..
<br /> K IN ACCORDANCE WITH
<br /> APPLICANT MUST PERFORM ALL WORTH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF
<br /> SAN AM COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT- OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY
<br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO
<br /> MA
<br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE
<br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO
<br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA."
<br /> TITLEDATE
<br /> APPLICANT'S SIGNATURE: �s T V a�
<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 /> Nam ;"�Addressg 1 cOs pA,% s ...= --- gr• lam• Phone#6
<br /> Signature
<br /> EH230038
<br /> (revised 1/31102)
<br /> i
<br />
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