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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE.3f°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. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> /� �ATANK RETROFIT <br /> g_PIIIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR(RETROFIT <br /> --------SPA SITS_p �'R o� 10 J 'JI .] _. __ RO __ _ �K�\-^, _. __ A __y <br /> I�3 ___ 1 '\ ______________p_�Q- c / <br /> ___ PROJECT CQY1'ACT 4 TELEPHONE p V V �- 5 SR 5 E5"9 15\P ; <br /> F FACILITY NA!ffi 1 ' ��//ll�I y _��_- -DDDR_-_ F_f______ Q_ l�___' <br /> A ___________ __ � \- DDDR_ _Sk_� 1 J_ W�I- / �- J}---- ---- PNDRB „�4 -- - <br /> Vl y <br /> C ADDRESS ___________ <br /> I ___________________ __ <br /> L CROSS 3TRBBT I' <br /> I ____________________________________________________ <br /> T ONNER/OPERATOR __________________________________________________________________________- <br /> Y �S yI f <br /> e_-_ ; P�RO-JNJ <br /> N <br /> - +- <br /> i <br /> a7_0)��n- « - <br /> c CONTRACTOR eulR � <br /> o N _ yOg- o------------------- <br /> ------------------------------- <br /> ' e7 ------ LJ-�---u--h-- axove <br /> CDDDR- <br /> T ----------------------60-15 1len Aque. nQSCA LIC C1r&5s_S � 2 ___1_43_ <br /> _)_CR INURER -Sc ________ _ _ _ ! ! " ! <br /> -'"------------------------- <br /> ----------------------------------------- <br /> A WORK. <br /> WORK.COM .a <br /> C OTA® INFORMATIO <br /> T ___________________________________________________________ <br /> 0 <br /> DDDR <br /> R t______________________________________________ PRONE A <br /> 39- � •' :;___________ PRONG p <br /> T HC SIZB C ICAIS STORED C I'QD <br /> T 39 UM Yc1PROUSLY DATE UST INSTALLED <br /> 50 Pl�OJ c1 EV <br /> A 39- <br /> N 39- <br /> K 39- f <br /> 39- <br /> 39- <br /> P <br /> LA pp`PPROVWITH CON'TDITION.I <br /> DSAPD <br /> N PARBVIEWFRS NAE NITH CONDITIRS) <br /> DATE <br /> V <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE. LAWS, AND RULES AND <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE RE�TIONS OF <br /> TIONCHRTI CERTIFY <br /> TBECOMEHAT IN THE PRRFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT eMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> FOLLOW NG: 'I TO WORKER'S COMPENSATION LANE OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> WORKER'S <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SEALL EMPLOY PERSONS SUBJRCT TO <br /> WORKeit'S COMPENSATION LAWS OF TALI PORNIA." <br /> APPLICANT'S SIGNATURE: '' I TITLB ��`✓//` IQ.` <br /> DATE <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 ackno edge this responsibility for the billing by signature and date below. <br /> NameL&_4 �',CQ_ Address OS hcha ne <br /> f Phone# �3 31+''1JQZ) <br /> Signature A�S <br /> EH230038 <br /> (revised 1/31/02) <br /> i <br />