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08/29/2005 15:43 2094643565 VALUED ENGINEERING PAGE 05 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3'FLOOR <br /> STOCKTON.CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXP14RES 90 DAY$FROM THE APPROVAL DATE. DO NOT wAFTE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT_PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPA1WFtETROFIT <br /> . .. <br /> --------------- --- ::. - ----------- ---TACT---TEIrE�.....------- <br /> EPA BITE PrQ©a ar -7 I -----------1W____ _________________. <br /> P1i0NE II <br /> P FACILITY xnrtr <br /> 7 <br /> u.c I (�_.V�'l�eis__1AQ- �rCDaS ------ R-� -7---- - - - -- <br /> ' �PRONR U "�J! � I <br /> ' C ADOREa9 1•�/ 1 a�.�-y G_ �,yf.,,� -- -------------------.... ....------ ---------...�. ....................... <br /> --------------------..I__.,... ... {E'= -R'=-=-----� ---- <br /> I. ; CROSS STREET _- <br /> T —.n...... ----------..._ <br /> I T I OWNER,/D�RATDR t pT+Dxn <br /> Y ; I I s.ea br raJ 20 q-51 a-0-1)0 5 e� <br /> ----------------- --- ---------------- - - ----- <br /> NE <br /> -- � ..------------------------ --------.. I ----� - .. .,------ ---8-�i'� '° "--' -`f-c--- - - ----' <br /> C COMRWTOR NAME <br /> i 0 +--�--... <br /> N CONTRACTOR hUDRESS---10,9 —) J/�p f �- �/(p �-{/ CA LIC tl ---------._ _ CLR.,4 --- <br /> ; L�lLL �r�""�j'�_•...,.. _ _�'_�,yy� "�`a�rr� ____.`_.r'____..�.....________ <br /> WOAtt.COMB. <br /> R 17MURER <br /> { C 1 OTHER A.NF'ORNATION -------------- <br /> r T .,....-------------------------.......,.. . ..-..--------------------_ ...------------------------•-' �--------------------.., r <br /> D 1 PHONE it <br /> Zoe--/�+� <br /> PHONE <br /> ------------ <br /> iir. ir ....... . _... -._______________________._,... .--________________________.. _____________-_______._ <br /> TANK. in U 1 CIREMI S �.t 57'ORROD�TrnR LY/PR[iIV]:OUST.% DATE. ysT I:xSrtJ,6HD <br /> _-_ I,Yt PP2. .� <br /> r_ <br /> li <br /> A <br /> N <br /> 39' .....r ......... ..... <br /> r <br /> L A PROVED APPROVED WITIT CONDITTOx( DISAPPROVED <br /> A (. n- Mn WITH CaNDTT2 S) <br /> N 1 PLAN RTVTEWRRS NAME DAT[i <br /> . ..........r i.r... rr rr.. ...........r.i i.r. .r i. ....... r.rr. r. rrr <br /> APPLICANT MUST PERFORM ALL KORK IN ACCORDANCE WITH RAN JOAQUIN COVNTY ORDINANCES, RTATE LAWS, Mb RULES AND REGULATIONS OF <br /> RAN JOAQUIx COUNTY, ENV.T.RONMSWAT, HRAIXM DEPARTMENT. OWNER OR T.TCRNa11D AdENC'S STgNATU.RB CRRTIFIRB THE VOLLOWING: "I CERTIFY <br /> TTTAT .TA TRn PERrORMANCE OP THE WORK POR WRT.CR THIS PERNIT IS ISSTISD, T SHALL NOT EMPLOY ANY PrRSOx IN 9IICH A HAMM", A9 TO <br /> BECOMr. aDHa'I;CT TO WORKS-R.'R C;OMPF.n.RAT10x LAWS OF CdtLJ.T'ORNTA." CONTRACTOR'S HIRING OR $77RCONTRACTIWO S.i GNATURE CERTTFIF.a THE <br /> FOT.d.OWixa: �'I CART11Y TRNT IN THF P FORMAxCn OF, ni& wORK FOR WITCH TH.i,R rRRM].T 1S ISSUED, I SPAT.T. RMVLOY ORP—TONG SUBJECT TO <br /> WORTORR'a COmnASATION LAWS or C:AT.T IA." <br /> APPLICANT'S CIG?NATURR: W4. TT•Tbr, Iwo# .� ..._ DATE ✓ !/�.1�. <br /> +---' ---------- -------------------------------- <br /> ------------------------- -- -------------------._...... .....__i. <br /> BILLING INFORMATION: <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 <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name �,[ t Seo (.a.(are.r4J Address Sl I P&Ci Aw, I sfk- ' Phone# Zoq-S�g-�3o3 <br /> ignature <br /> EH230038 <br /> 'I/31/02" <br /> (revised ) <br />