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07/28/2003 16: 10 4640138 ENVIRONMENTAL HFALTH PAGE 01 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3o r-LOOR <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 I /U ! PROTECT cONTAr. r. rr., IroNE (t rd <br /> I F I FACILITVNAME /i/�_�_�_,/_Pj)_�_.. I��'�'�_____._._. -------------- c 2 �s ��`,�_���___�/g� <br /> &PA sxTc ! IZ 110® 7 2•.V/66 _ __ <br /> • <br /> I A }--------------- ..._ 1`1� 1 3 69 312 s <br /> --- -- <br /> A=E <br /> c iI t -----g-- <br /> L I CRORS STREET r / <br /> I I h6W-�--- GtGr"k NsCn---- ' - <br /> ---------------...---------------------,------------------------ <br /> I T I OWNER/OPERATOR G m I 0 <br /> I Y I qj', _...-�'�iole x•s, r IF'O----------- ------ - -----------------*-- - <br /> { C I CONTRACTOR NAM@) PHON'F H6 - 3 YO,.•---- <br /> -- <br /> ------- �� <br /> N CONTRACmR AOORR4$ - - <br /> .5f. 4.73 a`^�ntW r,.Tc *< TeZ 2/l/ I cuss A <br /> I T ----------------- �� �'/rfr,.. ! <br /> ------ <br /> I R NIS IWORK.COMP.p -- -- ----" - <br /> i A <br /> I Q°w6lc t�-------------------------------------+--- /S4, X76 0l <br /> -—-------------- <br /> -- <br /> I•--- <br /> C OTHER INFORMTION <br /> I <br /> ----------- <br /> O (idh t-- -- : pd-- Cit -------------------- PHONs iy//93.5\J S�f7'77Q/ <br /> R } -- F <br /> I I PHONE R I <br /> .... IIIIIIIIIIIIIIIllltll{I111111111 <br /> --------------------------....-----------------------------.-..-------------------------------I <br /> I i TANK I➢11 TANK EI7,Ti. / I CI?EMTCALS STO/RED CJRRFNr,,Y/PREVTOUSLY I bATZ UST IMMALLEO <br /> as• �O JO t� (�G zdc Lew s v/:r e I t/Z/h'•Yo�/A/ <br /> I T 1 39-_ <br /> I I I <br /> i A l 3g Z ,/D 00Jw, <br /> N 1 39- I I <br /> I <br /> K 39- <br /> a9• <br /> -••IIIIIIIIIIIIIIIIIII11iIII��IIIIIIIIIIIIIIIIIIi I/' 'I•Iillllllllllllllllfl�h'l{[llllllllllllll1111111lI1111lIIIIIIIIIIIIIIIIIIIIIII <br /> 1 L I APPROVF,,O APPROVED WT Yr: CONDIT-M';9) DISAPPROVED <br /> OR <br /> ! N I PTAH RM' EMS NAME S y UATR <br /> *---I{11111111111{IIiIIIIlllllllllllllllllllllilllll�l'III111t ' I' II {I � IIII{IIIIIIIIIIlillll IIIA 11111111111111111 <br /> I I <br /> APPLICANT MUST PERFORM ALL WORK TN ACCORDAMCr W'TT; SAN -OAQUIN COL:vrY=1 ATE LAWS, AND RTJLRC AND RI*ULATIOWS OF <br /> BAN JOAQ=N CODNIY, RNVTR0;7KIrTTAL IMUT14 DEPARTM'n.AT7 CWNT3 OR :.TC 4,qF—' A7FW,'5 STGNATURC CERTIFIES THE FOLLOWING! "I CUTIFY I I THAT IN THF <br /> PMU`ORMANCC OF THE WORK FOR WHSCH T1419 PERM=T IR =95T0, I SY,AT.T.NOT EMPICY ANY PER90N IN 9VCH A MANNER AB TO I <br /> BEca'm 9UBJECI'IC1 WORKRR'S COMPL•NSATION •At:S CF Gw=FGRNIA." C0',M?ACI'OR'R HIRTNG OR N9CONTRACTING SIGNATURE CERTIFIES THE <br /> I FOLLOWINGi "I CERTIFY THAT IN THE PERF0PMAr1CT•1On TI'TIT WORK FOR WHICH THIS PERMIT 19 I9amm, I SHALL EMPLOY PERSONB HUBJECT TO I wORKER'S <br /> COMPT7d9ATTON LAWS OC CALICORNIA," <br /> I I <br /> I I <br /> I APPLTCANT'S SIGNATURE1 �C'/�Y� AW T7.7.13 lj B'eO IOX DATE <br /> I <br /> i.. ,. ........ ..... <br /> BILLING INFORMATION' <br /> Indicate the responsible party to be billed for additional EMD staff time expended beyond permit payment <br /> coverage per tank. It the party designated below is different than the permit applicant, e.g_ property owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name,447efrcar* C,c�nyr/a�f/p.-..AddresS S�-- A4,6 3Phone# 4 - �1G -J 6Do <br /> 13ren�wC�:c� C/f 9�S/j <br />