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SAN JOAQUIN COUNTY [RECE " ED ENVIRONMENTAL HEALTH DEPARTMENT NOV 0 8 2004 304 E WEBER AVE,3�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 REPAIRIRETROFIT UNDER DISPENSER CONTAINMENT REPAIRJRETROFR -----------_-----------------_----------___________________________.......................___________________-------_______________ I EPA SIT2 II 1 RAQTBLT NELALT E TEISPROM I I 1 ______________________________________________________________________________________________________________________________I I F I F CIL TY IIID I PZR E p 1 I A w------------- LSf1_SSf _ .o.!� -----------......../..----••-----------z°9 333•-IiY3/. t . .. Z ------------ ......... I I L I MSE STASSP Ii r---•• ---•---_----zoo-pf -------------- --------------------------------------------- T I T L rn¢iEA/OPIRATOR I PRONE 0 I IYI ------ Te rri ---•--.....---••----•-- ...ass :_ 5 ---------- CHTRALT.VI I C I CR'MME 1 FROM 0 I QWw1Q ...............•----._. ._....... -••-----------•-• -------------- T -------•----•-- L A I CQPLRALI.A AbgiESS r 1 p� pp�� 1 CA LIC - I Tr 0...___62.7 .li.-__�Y _..7I_r LOL__ 74/3/<Pa_.I `LA's A... ------•••I LEI namm I WORK,LTDiP.p I IA I____________________________________________________________________________________w-_______ I C I OI7fER IA6tIIOLTTI@7 I I 1 T _________________________________________________________w.-__..___...__....._..______._____...__________._..___.__-_._1 O I I P"M S 1 Ift .-•-_•__________............................._•--___________-_.__-____ I I I FIM 0 I t__.IIILIII11111111IIIIIIIIIIII III ____________________________________________________________________•___.---____-____---..____1 I I TW ID p I TAwc size CR0IC sro m LT =TILT/PAEYIWELY I o=on INSTALLS❑ I 139- I I T 1 39- I I IA 131- 35.- 39- 3q.- 39 3-39.39-38•39I I I I A ---IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII FI I I L I APPROVE 1'EROVVPD WITH C@IDITI011(SC1 _ oISAFPROnD AI (^u ES ATIACAW.'•f NTTH CPMO;TTIX0) I I W I PLAN REVIEWERS NAME n'8.>�l�Cy ly(P'S�t• R.E. k 1 ,___IIIIIIIiI IIIIIII III II IIIII IIIIIII ILII IIIII IIIIIIIIIIIIIIIIIIIIIIIIII IIIIIII IIIIIIIIIIIiII IIIIIIIIIIII ILII III II IIIIIII IIIIIII L I APPLICA.NF K91sL PEPFCfc• W ALL WORK IN ACCORDANCE WITH 6Ni TOAOUII9 CONtIY OROIbWD1Ca:. sLAtE L7315, Atro RWceb AKID RECJLATIOIIS OF 1 t SPO 30A0OIA ml]NrY, RWVIRCpmffltPAL RERUN mPARTF44i. WMER OR LICENSED ACEEL'3 src4nTURE CE&TiF THE FGWLOW3RO: "I CERTIFf 1 TMLT IN THE MRSD im" OF TN. WORE POR WHICR TRIS PERMIT Is IS90m, I SMALL NOT 1MLOY ANY PER9W+ IN SUCH A MMRMR AE TO I 1 RK*M SU XCE TO WORKER'S C0�6^RA.TION LAWS OF CALIFORNIA.- MM=R's M1210 OR SUBCOMRA(71210 SIGMATURE CERTIFIES TAE I I POLl4WIAO: •I CERTIFY TINT Em Tm PSRFOenua:B OF THC WORK FOR WHICH TRIS PERMIT IS ISSUED, I HHAIL EMPLOY PERSONS SOB3ECP TO I I WORKER'S CW MATION IAWB OF CALIFORNIA.- L I I I I I r7 I aPKmxeaNT'9 si0emT9Re Trrce i'7L�7/o/A�/�Yl.✓.G£YW mae ��'�O� I BILLING INFORMATION: 'll` ov -hlig� L�� \. co*�O c -No scxc -T'e� cX= 9v o0 _%V Ls 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 party must acknowledge this responsibility for the billing by signature and date below. Name Address __ Phone#___ i