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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENiF.R 1 0 7005 <br /> 304 E WEBER AVE,3"P FLOOR <br /> STOCKTON.CA 95202 ENVIRONMENT HEALTH <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT PERMIT/SERVICES <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 /> I SPA SITS # i PROJECT CONTACT E TELEPHONE # PHONE # <br /> -__ _--- <br /> --------------------------------------------------------------------------- <br /> F I FACILITY NAME F-\ L __ _�/3 �____________ r _lJ� _---- <br /> A -- <br /> i � ��/� <br /> A +_______________ ___ <br /> C I ADDRESS -05C) l S__-- _1_-- <br /> -/LC�1.C�v A— ---- ----- '-- — ------------------------- <br /> L I CROSS STREET <br /> I +___________________________1_________V_____________________________________________________________5___q_____5_____5________________ <br /> T 1 OWDPHONE <br /> iY i ______________________________+_ % _ <br /> ; <br /> X31 <br /> C I CONTRACTOR !TAME A\Gl��. __ 1eg,�,��1_�N'_R—____ PHONE #nO)�_G,-]!9 <br /> 0 +____________________v^ }.L1,^ �1111rr 1St 11 bSSGL_lu�L <br /> N i CONTRACTOR ADDRESS LIC %-JWW CA_ CLASSf1 <br /> L Y-yc <br /> i R 1 INSURER i WORK.COMP.# <br /> A ;____________________________________________________________________________________+________________________________________; <br /> C I OTHER INFORMATION - I <br /> ' T ------______ ____________________________________________________________________+________________________________________i <br /> 0 i PHONE # <br /> IR +______________________________________________________________________________ ; PHONE # <br /> +___iiillllliilllill:llllilllii„ ________________________________________________________________ <br /> TANK ID # TANK SIZE CN@dICALB STORED CURRENTLY/PREVIOUSLY DATE OST INSTALLED <br /> 39- <br /> T 1 39- <br /> A ; 39- <br /> N 1 39- <br /> K 39- <br /> 39- <br /> 39- ��� ��������... <br /> P <br /> 1 L <br /> APPROVED ff' 11NITH" ��ITI"(S _1DISAPPROVED1111�" '��"" <br /> A (SEE <br /> A?'I'Ac: WIT COND ONS) DATB 3 <br /> N PLAN REVIEWERS NAME\� C►d.%��We' <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN NCE <br /> CO ORDINAS, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN ,IOAQUIN 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 /> 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 /> APPLICANT'S SIGNATURE: C /'C TITLB C1, -L.1/41J1�� DATE <br /> __________+ <br /> +_____ __________________________________________________________________________________________________ <br /> _ <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 /> Name \ ress ip.o. G6x Oi ''R r.APhone#-id-1 616:91W <br /> Signature -/ I <br /> EH230038 1. Qat la%6D cw %3�" sO�i6o Z <br /> (revised 1/31/02) <br /> 1 <br />