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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT FEB 0 7 2003 304 E WEBER AVE,eo FLOOR STOCKTON.CA 95202 ENVIRONMENT HEALTH APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT PERMIT/SERVICES THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: __TANK RETROFIT ✓ PIPING REPAIR/RETROFIT 1/ UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT I -I EPA SITE » CAL_000 URI- I PROJECT WNTACf 6 TELEPHONE q ��- �`�,'__Ci.(ZS� ________________ -------------- / 1 F I FACILITY NAME _ 4e 1fp f-c- ZZ 3'7 — '6Z! '7 J___________I P �� 939- 06'7 I Ai_________________________________________________________________________ ________SY____ __________________-_____1 I C I =KESS G(c] G(3 1 , S+_d-a !�aJ!t 4 S f» f, CA Q S21 S II *--------------------------------------------------------------- -------------I I L I CROSS SIREEI I I --------------------------------------------------------------------------------------------( ------------------------------ T I OwNERJOPERAIOR I-C"ZY �=YI G, I PHONE Y I Pb 3zx :_'7 11 -_Ll__r.'IIe.S- T3`- -vrvz . f ' ` N`h° -c I COUM CIOR NAME G' -k I $ef I PNoeo, » �zS� 3ss'- Z.r�zeo 1 1 p ,__________ N I CONTRACIGE ADDRESS {�[,Stl P.,.t/g.,ee��. I.L'',.e.. 11.{e N I CA uxc » -7 Lj GI 3rn I CLASS IT ---------------------XS!lc. p-----g6,hr---------------------------------------------------------------------I R I xwsuRSR��.� Qo saf[o-I {-MLv✓�NCG rvWLc7 I UPI(e 1634- -o3--I r- woRx.cGK4P.» C OMEN INFORMATION II 1 T a_______________________________________________________________ -_________,____-_-_-_____________________________i 1 0 1 I PHONE » R __________________________________________________________-______________-___________,____________._____ ___________I I 1 FROM » ___IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII____ _______________________________________________________________________________I I TANK ID » TANK SIZE I CNE ICALS 3TOA® CURRENTLY/PREVIOUSLY I OATS GET INSTALLED I 139- PI I IU/s.�o cue J/u V. I C4C-5 y,1 gin.. - 1497 I T 139- Z I / ?'� /{ mambol;w 1:JIx 74'7_1 A 139- IT 3111- a"� 4.{meq I Cva-Se/,w� I 'ALP . 144-F INI39- I I 1X139- I 1-1 I 139- 1 39- I 1 ---I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I II I I I I I I I I I I I I I I i l l l I I I I I I I I I I I I I I I I I I I I I I I I I I l 1111111111 1 1 1 I I I I I I I I III LPI APPOVWITH CONDITION 1st _ DISAPPROVED A S WITH CONDITIONS) N PLAN VEwsasME ® rs 1 DATElo *---IIIIIIIIIIIIIIIIIIIIIIIIIIII 1111111 II II 111111 (IIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIII11111111111111 111111 IIIIIIIIIIIIIIIIII I APPLICANT MUST PBRPONM ALL WORK IN ACWRDANCB KITH SAN JOAGUIN COUNTY ORDTNANCPS, STATE LAWS, ANO RULED AND REGULATIONS OF I SAN JOAWIN COGNIY, ENVIROED94YTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY 1 I THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL HJT EMP10Y ANY PERSON IN SUCH A MANNER AS TO I BECOME S,9 E= TO WORREN'S CO PENSATION LANE OF CALIFORNIA.' CWIEACIOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE EOLLOWINO: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICR THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I wONxESt'S COMPENSATION LAWS OF CALIFORNIA.' I I I APPLICANT'S SIGNATURE: [ '[it/'L / ' `�-V TITLB ` '�5/ 4 DATE z� ___________________________________________________________________________________________________________________________________ BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the parry must acknowledge this responsibility for the billing by signature and date below. �r(&C_jer e7n ksw'> t�+c ( Ir-672-1e_Lar5r9eW\ D4. t4,4 Name Servlces,I T4,. Address /�1'kt (fro� Wy 98z-zs Phone# 1