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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WE13ER AVE,3RL'F L'OOR <br /> STOCK F'ON,CA 95202 <br /> APPLICATION F OR UNDERGROUND TANK REI ROF 11,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM T 50V� <br /> DAT&.DjQ.NOTWRj-j iNAN �SH±P I D BELOW: <br /> rr- I .LUAREAS. N ICATE PERMIT TYPE <br /> P <br /> P;p <br /> R RE <br /> .-_jANK RETROFIT 0-$Pd wlm� UNDER DISPENSE?CONTAINMENT Rr-PAIPJRFTROFIT <br /> 1 E.PA SITE 4 PR0,19C.17 C.ONTACT TELIF31110NE lid <br /> 1 F FACILITY NAMIR PHONE* it <br /> A <br /> 1: ADDRESS <br /> T I <br /> L CROSS STREET <br /> T oWND.R.40PPRpe'l <br /> /F.C, PhONE It <br /> Al-'Aj�e_--_ I <br /> 00 M)11- -e-------------------- ---- --------------------- <br /> C CONTRACTOR NAME PHON8 It'7z(O" <br /> N CONTRACTOR Al�)DRKSS <br /> A <br /> Af <br /> (�A <br /> V0 <br /> I ullu W)1�9..Cump." <br /> A ------- <br /> C OTHER INFOR14ATION <br /> T ------- <br /> 0 PlIoNE 11 <br /> PHONE k <br /> TANK ID TANK 81�&I] CHEMICALS S'I%)RED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> --------------- <br /> T :39 <br /> A ............... <br /> ..................... <br /> N 39- <br /> K 39 <br /> .............................. <br /> 39......... ......... ........ ...... ............. <br /> il -7 i7i --..T.1.1.1111 ...... <br /> .......... <br /> i P <br /> L ! PPROV91) APPROVED WITH CON 1)IT I of,,'k S) OLSMPPROVEI) <br /> A IIE'ATTACKMI11IT WITH COVDITION01) <br /> N PLAN REVIEWER$ W." DAI I". <br /> .. ............................�:.;�.". .,;.� �-..�....7---,;-i7 � �_;1--5, 1------------- <br /> APPLICANT WIST PERFORM ALL IN ACCORDANCE WITH SAN JOAQUEN COUNTY ORI)INANCES, STATE �1,AWS, AND AND REGULATIONS OF <br /> SAW JOAQUIN (.X)UNTY, ENVIRONMENTAL HEALTH I)PPARTMENT, OWNER OR 1ACENS1,U) AGh:YJ-,-, SIGNATURE THE f,-OLLUWXN(,: 'I CERTIFY <br /> THXT IN THE PERRIRMANC.7 OF THE WORK FOR 1414101 TH18 PERMIT IS 1, SUIALL NOT �NIIWY IkNY VIJZ.%30N JN �;UCTT A MANNER AS TO <br /> BECOME SUBJE(71' 'TO WORHERIS COMPENSATCON fAWS OF CALTRORNTA." CONTPACTOR'S OR 1UI3',.()NTRACTiNG SIGNATURE CERTIFIRS THE <br /> FOLLOWINCz 'r CERTIFY TkWT IN THE Pfi-2tFORMANCE OF THE W)RK FOR WHICH T141S' PERMIT Is :[SSUE.:), I SHALL PMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION 'LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURRi ATE <br /> TURP <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 ddressaw <br /> Signa <br /> EH230038 <br /> (revised 1/31/02) <br /> zooln IVINMNOUIANH IIVI TIOTS999T6 XVJ TT:60 90OZ/TZ/LO <br />