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09/26/2002 14: 17 2094683433 FIFTH FLOOR PAGE 03 <br /> SAN JOAQUIN COUNTY ����' <br /> ENVIRONMENTAL. HEALTH DEPARTMENT <br /> JOa E WEBER AVE,3"O FLOOR <br /> STOCKTON.CA 85202 <br /> APPLICATION FOR UNDERGROUND TANK RFTROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EYPIRP3 00 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW. <br /> Q <br /> _TANK RETROFIT PIPING REPAIRJRETROFIT UNDER DISPENSER CONTAINMENT REPAIR(RETROFIY <br /> -------------------------- - ----•---- - -------------------------------------------------------------------•-------------- <br /> ' I EPA SITE 11 I PRW= OOVX ICT 6 TBLEPHOt,•E p I <br /> ------•--•-- ---------------------------' ------•-•--------------------------------------------------------------------- -- <br /> F I PACII.I,Y W.`s 1 <br /> A .......... •-•- ----- - P}'�-------------------------------------------X30---- .�_�'� - s <br /> ICI ArDPLESS <br /> I L I CROSS sln= <br /> M <br /> I - ---------------------•-•-�Y7l14 <br /> ---•------------------------._.....-I-- <br /> T I a�/oPas:rzzrne I <br /> Y ........................��.�� .._cop -'S- (!. <br /> I <br /> ---- ' P2+Otab Ir 3�c� <br /> I H I ONT ACTOR Ammmis I 18, <br /> ` �„�{y-� I CA LIC @ 17f q <br /> VV J C �-�F.JU W. l I <br /> I T•------------------- IA-------------_�---------i----------------------- �-- g g---! s 1 GQ�� <br /> I <br /> 1 R I INSaR� s t F�'�2 Cr,�1 I --------- e 02 c,t!rt t (03s� <br /> IAI---------------------------------------�:..----------------------•----------------•------------ <br /> I C I on= nsawmcw <br /> IT+--------------••-------------------------------------- --------------- <br /> I P=M i 1 <br /> IR•----------------------------------••--•-------------------------------------------- ---------------------------- <br /> I I -'- ----------- <br /> I <br /> I <br /> - r <br /> IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII------------ ------------------ ----------------------- - -------------------------•- I <br /> I I c ASK ID d I TANK SIZE I 0fl3<IIAIS MRM CORRIyZY/129SVI00SLY I DATE UST IHsTAI XD <br /> i I ]s•1j�] /1")/,�Za1L. I 1 L�95oc-S/V 2; I I <br /> T 1 79' 519YL' I I I I <br /> I A119- <br /> IpI ]9{0� I I I I <br /> I <br /> I ` I I' I I S I t M I I <br /> I 19-C7/ r <br /> )9- <br /> I I I I <br /> ___IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII , IIIIIIIIIIIIIl1111�IIlIIIIIIIIIIIIIIIIIIIIIIIIIIIIlIlI1111111Illlllll <br /> I L I APP APPROVER w2T1R LO27DITiCl1( DL6APPFOVBD <br /> IAI S 002tDITIQ�I I <br /> 1 N I PLM RLVLYjrF35 ttAF16 �If <br /> DAT=lll ..I�; I '�INIII �I 111111111111111111111111111111111 111 IIIIIIIIIII1111 <br /> I I <br /> APPLICAETT MOST rSRFORN ALL wom nz ACCORi'I Ncz wITH star Jmo= COUTTY OP DQuCm9, STATE LAMS, AM Mn-S ATM RB6•ULATIclue OF I <br /> I "N JOAQUL4 O:um, EFtIR/R cwmL RmLTH DEPAX-m-M. M;ZR OR LI=QED AGISST'S SIRAR74R.8 OffTIPIES SHE FC7LL0S-=! •I CIIRTIPIC I I THhT IN THE <br /> PERIWJQ4 N= OF T�--NDR:C FOR WIC1 THIS PERMIT TS ISM=, I SHtaZ XCT 01WWY ANY VOLICd ITC SUCI A W.IWP.R AS TO I <br /> I BECOME SuRY CT TO WORKER'S OWENSATIOd TANS OF CALIPOINIA.• CON7RACTDR-6 HIRING OR SUUOC2..7 ACTING SIGMA VPZ C MTIPIES 'UM I <br /> F0rALNrWGt •I CERTIFY TMT IN TKB ?EPJXN*WCE OF UM WORK FOR 1HICH THIS PERMIT IS ISSOED. I SHALL MVI= PERSCOS SUBJECT TO I I w06S1m,S <br /> CCMPE21SATION LAWS OF CALI MXNIA.• I <br /> I I <br /> I I <br /> I I <br /> I ArPLIf7atT'b 6IGtA1VRa: TITLE£I,T_14 S l oc g,%r I Snp . 11ATa I <br /> I ( <br /> ------------------------------------------- ------------------------------------•_---------------------•---------------- <br /> BIWNG INFORMATION: C G <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 owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name Address Phone# <br /> 1 <br />