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<br /> SAN JOAQUIN COUNTY
<br /> ENVIRONMENTAL HEALTH DEPARTMENT
<br /> 304 E WEBER AVE,3RD 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 /> _TANK RETROFIT_PIPING REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT
<br /> +_____________________ _______________ -------------------------------------------------------- }
<br /> I BPA SITE # I PROJECT CONTACT R TELEPHONE #
<br /> P 1 FACILITY NAME — 11:ni-&\ v d'_ 1!`_- 1_ __ ______________________ PHONE # 3_39 7 ------!
<br /> �^_!J 18d� y
<br /> A + - -- - Q - - 33
<br /> C I ADDRESS ,t 1 __ --_
<br /> 1 L I CROSS HTRBHT .1{.!r'u
<br /> 1 T 1 OWNER/OPERATOR " �(t. PHONE #
<br /> 1 Y 1 ``VIl � --- l_Y1 04 1
<br /> C I CONTRACTOR NAMEZ-- .-JC►1 V�C A __ ,�"RA, -r�� -7-0m- #__
<br /> U /� � t1ly_ILl1#I�,�`.1y.J�/ 11 Au1(�
<br /> CONTRA
<br /> 1 N ------Cl'OR ADDRESS"-P,0. M_ 4�-- —-- ._____�_-- LIC______133159_____�ss__AJ�_S_K_______�
<br /> I T +_CONT____ _ /.RE ��CL '�,/����(�����',Csn2l_ (+ /�'`h p 'l
<br /> R INSVRB11 I�1 Ql�__ ____ ___+ `_t7NLlw'_S _____________________________I WOR-.COMP.# AI_SLVY��_tILQY��_____1
<br /> ,
<br /> A 1 --_V.� __ - __ }______________
<br /> I C 1 OTHER INFORMATION 1
<br /> 1 T +____________________ 0___ ________—'�l.nn_lmuamu-___________________+_____________�_,_r �s ___
<br /> 1 0 1 , PRONE # ql� 1�3��pI(� 1
<br /> __________________________________________________________________________ C ____________________________1
<br /> I PHONE If
<br /> }___111111111111111111111 „ ______________________________________________________________________________________________
<br /> TANK ID # ""„ii:i:!,11" 1 TANK SIZE
<br /> i CIDHdICAL6 STORED CURRENTLY/PREVIOUSLY 1 DOTH UST INSTALLED
<br /> 39-
<br /> 1 T 1 39-
<br /> 1 A 1 39-
<br /> 1 N 1 39-
<br /> 1 K 1 39-
<br /> 39-
<br /> 39-
<br /> +___111,,,,,,,,,,,,,, , ,,,,,, ,, 11111111�,,,, 1 R 11111111 L1111111 ' ,,, ,.„.„„. ......,,,,
<br /> I P i
<br /> 1 L 1 f APPROVED �ROVBD WITH CONDITION(p'lgi„ DISAPPROVED
<br /> I A //� /I S�H ATTACHMENT WITH CONDITIONNS(�`
<br /> 1 N PLAN REVIEWERS NAME ll'P "J(' DATE
<br /> ., '�1,,,,,
<br /> APPLICANT MOST PERFORM ALL WOR- IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF
<br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: -1 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 /> WORXRR'S COMPENSATION LAWS OF
<br /> CALIFORNIA./I^�
<br /> APPLICANT'S SIGNATURE: \./` YINVw� TITL DATE I1
<br /> v
<br /> 1 ,
<br /> +_________________________________________________________
<br /> BILLING INFORMATION:
<br /> Indicate the responsible party to be billed for additional EHD staff time ex I ended beyond permit payment
<br /> coverage per tank. If the party designated below is different than thF Iermit applicant, e.g. property
<br /> owner, the party must acknowledge this responsibility for the billing by sig,.ature and date below.
<br /> Name Address Phone #
<br /> Signature
<br /> EH230038
<br /> (revised 1/31/02)
<br /> 1
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