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--- --_ --- ricin rLIJUK PAGE 03 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 904 E WESER AVE,37 FLOOR <br /> STOCKTON.CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> - THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW; <br /> �Jr? - ZANK RETROFIT^-PIPING REPAIR/RETROFIT_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> �-••�'EPA SITE # _______________________i PRGJECI CONTACT 6 TELEPROPS # �m� WoLp(YIL <br /> I -------- ....�cl�tG` .. 5- ... + : ~C C`' �o <br /> I P I FACILITY NRNS <br /> IA x_______________ I PHONE # _ ' <br /> - qo 4° .. ST._1�A�-�-- SCG J .t�__ -.a 5-Za(1_ I <br /> SS <br /> I ------------ I <br /> L I CROSS STREET I <br /> 1 +-----'....---------------------------------------------------------------------------------------------------- --------------I <br /> I T I OWNER/OPERATOR �� (1, <br /> 'G I PEONS R <br /> Y I 1 RIC �JOL�rJ ' 20R qyZ- IS�o� 1 <br /> I---+--------------•--- - ------F-1--•--------/-j-- ------A- `---------L------ -------- --- ----/-- - ------......-------•I <br /> C 1 CONTRACTOR NAME �?l 114 � -=__L� LJA'�3_...--J^!5-----------•----------I PHONE # 1 q25� S� ?�j� ---- <br /> I C I COW -------DAME.. 4a1. \\\ <br /> I N I CDNTAAG7OR ADLM S LIC R 1- I CLOSE I <br /> 1 T +------ ---- -------- ¢ _�7__Sl � ...el S�E}Y-QUl�✓.�q --- - --- Z�7�] _... �i/� � -1 <br /> I R I INSURER <br /> CA ________________________________________________________.________-x-_______--.-__ <br /> G---- I------- -- I I <br /> OI 1PHONE # <br /> IR a_____________________________-------------------------------_-----------------------t---------------------------- <br /> • I PRONG # <br /> ! IIIIIIIIIIIIIilllllllllllll11111•------- -•-------- --------------------------------------------------------------- ----------I <br /> I TANK ID # TANW SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I OATS DST INSTALLED I <br /> 139-0007--'mctn olA/o3f� Jnfn,YL� I ��f�.p� ' nl <br /> IT139A 30- <br /> - 1 I <br /> I N I 39- <br /> I R So- <br /> 30- <br /> 11 <br /> 9-3#-illi! Illlllllli I, Illlllii i�Lllliilii IIIIII'i Milli IIII I I II 'i i I IIII. „ilillll Ali Illillii hill lliil <br /> LI <br /> L I APPA APPAOVEO WITH CONDITION( �. DISAPPROVED <br /> I A (6 ACAMjN WITH CONDITIONII I <br /> N I PLAN REVISNt3S SAM / T DATE <br /> +--•IIII IIIIIIIIIiilllllllil Ii1T111 I. . IIII rH VIII VIII (IIII II II11 11111111 III IlIi.11. .1 <br /> APPLICANT GRIST PERFORM ALL WORK IN ACCORDANCE WITH SAN ,IOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> I SAN JOAOUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AG:ST'S SIGNATURES CERTIFIES THE FOLLOWING: -1 CERTIFY <br /> I THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUW, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO I <br /> I BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA-- CONTRACTOR'S HIRING OR n-aCONTRA=%M SIGNATURE CERTIFIES THE <br /> I FOLLOWING: -I CERTIFY THAT IN IKE PERfORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY FERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIF IAN IA." <br /> 1 � I <br /> I APPLICANT'S SIGNATURE; 6'V� TITLE A4�klr� <br /> I I <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. propert} <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name 0ffl (L-��/A�)- / Address (j 7 SI`-T-Pj C C Phone # <br /> Signature Nj <br /> EH230038 <br /> (revisedised 1/1/31!02) <br /> 1 ' <br />