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61/18/2005 17:11 26946834' FIFTH FLOOR PAGE 04 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 S WEBER AVE, 3°0 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 W RITE IN ANY SHADED AREAS, INDICATE PERMIT TYPE BELOW: <br />TANKRETROFIT PIPING REPAIRIRETROFITUNDER DISPENSER CONTAINMENT REPAIR/RETROFIT --- -_ -r <br />---- ------- --------- <br />1 q� <br />-------------- — -- <br />... .. .. i PROJECT CONTACT 6 TELEPHONE dJ l�L 1��1 LLQ <br />J -90. SITE # <br />--�� tom.._ <br />Pmm <br />F I FACILITY NAME H_- ✓ /_`SG ---'--•--------------------- -•-------------------------- <br />A <br />------'------------- <br />R +------ ---- ,/ �, _ / � <br />J 1 <br />C1I ADDRESS J. ��L�-_C11� •-i -- 1:11.-1- ✓.UU�La�l.------------------------ <br />f -..-- -- - <br />I L I CROSS STREET // //��LS1_�u- --------------------------------------------------- <br />(, <br />i ---------------- -- --� P NE # <br />T I 0 g/OiERATOR <br />X I`�'.L�-..�C� _�rQl 1� �_1------------•------- --- 7( r .7_-�_JCJ-- ---- <br />----- <br />/J /1��) PHONE-- l&. ) <br />C I CONTRACTOR NAME /}%--- / U �![LJ S��- �UI--------- <br />----------- <br />Y <br />-- I -C11�} S . <br />Ti... L -------- --------�---...---- <br />0 +------------------ -/�'�- - Ss .. <br />J 71, <br />N I CONTRACTOR ADDRESS �i�J QC � L� CA LIC # 7� f_7no IU H <br />Lt �.�_�__------------ ---��---- <br />T + ....------ --------- ----- ._ /- - I WORK.COMP-4{ %-j([ /j�/� `2� ) I <br />R INSURER �n ----- ----'-----+-^.--------•-C C_1.1 :5....!__LCiLI�� <br />---- <br />IC ------ --------------- -I <br />CI OTHER ---------ION-------------------•--------------- '------- -'•------ ---------r--'•---------- - ------------- <br />R <br />- <br />2 r-- I PEONS # <br />--------------------- -- <br />----- •• ---------.- PHONE # <br />I R r__.... .- -- I <br />_ _ �•-_--------- <br />--------------- <br />--- -••I <br />--------- •• .. <br />I <br />TANK SIZE i CK CALS TO CURB TLY/PREVIOUSLY I DATE UST INSTALLED I <br />TANK ID �! I <br />I I <br />29- <br />39- <br />39- <br />V <br />9 -39-39- <br />K I 39- <br />I 139- <br />39- I 1 11 III I I 1 11 II <br />+•_-JIiJIIII�IIi M1111illlllii... II r IiIII JIIIII IIIIII illllli {IIIIII I Bill V III I IIIIIII ilill�I�Ii <br />L ` -— APPROVED c�AAPROVED WITS; CONDITIONS) DISAPPROVFJ] _ <br />—T 1hrrIMMT WITH CONDITIONS) o2g'p g <br />PLAN REVIEWERS <br />Illi{IIIA !II{{ <br />DATE <br />II��IiII VIII IIIIIII II {Iji�i <br />I <br />STATE LAWS, Alm RULES AND REGULATIONS OF <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINAVC£S, <br />SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTfi DEPARTMENT_ OWNER OR LICENSED AGENZ NOTIEMPLOYEANY pEASON INESUCHLAWIMRNNER"ASCTOT Y <br />THAT IN THE PERFORMANCE OF THE WORK FOR WRIC{ THIS PERMIT IS ISSUED, I SHALL <br />BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S FIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THP I <br />FOLLOWING: "S CERTIFY THAT IN THE PzRFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 159UEO I SFIALL EMPLOY PERSON SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." { <br />I <br />� I <br />/L l/U7 TITLE /` DATE <br />APPLICANT'S SIGNATURE: TT <br />� <br />--------^----------------- ------'-------- <br />--------------------------'-------•--------... <br />- --- •------ -- " _---+ <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit paymer <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 Address Phone. # <br />Signature <br />EH230038 <br />(revised 1131/02) <br />