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01113:!2000 14:06 46401:38 ENVIRONMENTAL HEALTH PAGE 02 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WERER AVE,3"O FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT E)PRES 90 DAYS FROM THE APPROVAL OATS. DO NOT WRITE IN ANY SHADED AREAS,INDICATE PERMIT TYPE BELOW: <br /> rTAW RETROFIT �PIPINO REPAIRIRETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROPIT <br /> --------- <br /> C I $PA 87'!E 8 I PROJECT CONTACT 3 TELSPHO M f 5"1 <br /> (I{ I . .0..5....---- ......, �- ---- :Q•- - - >"t— -----. .7&'-1 <br /> "--t'e <br /> _-.....- -- - � <br /> F FACILITY NAME ......... --------------------------------------------------------- <br /> A <br /> C ADDRTa^S 7 -- ...... ------------------------ <br /> -------------- <br /> -------------------- <br /> L <br /> ----------------------- <br /> ------- ...... <br /> «_ .............. <br /> L II}I <br /> I CROSS STREE7L �vKC v� <br /> _.....- - ------- -- - ------ - ------------ ------ --- - ---- ------- •I <br /> ------------------------------------- <br /> 'i pKNER/OP^sRATOR f` VAONE � + <br /> ---------------- <br /> I�C-I•COMPAMRNME - � r- pHaNE !! Z_ �._..... <br /> ------------ , _ <br /> 0 {I <br /> II N +i--------------- <br /> CONA6dADRESS � - - <br /> - - - ---------- <br /> -LICPS - <br /> a ---------Z-•----•-I <br /> WORK <br /> R { ITiJtSR ----__+--- --�------ c- .73�:.o�� <br /> c I-OMIL-IMRMP'noN -._...... .....-- - ---- ------ -- --- <br /> � I --------------- <br /> 0 - ----.._..._- - <br /> R -------------------------------------- - - ------------------ <br /> -- <br /> ONE 0 <br /> 1+-• ill{111111 N IIlIIfllllll{Ilill ..' ---' --•- -- ----- <br /> ----...-..--------------------------- <br /> { <br /> 1II 1LaL ��csSaiveLY�jPAYI0S3LY � TALL= <br /> TANK <br /> TAN% IDM TANK SIZE MIM CR�1-1------- <br /> -------------------.- - M2 <br /> gg, <br /> 39T I <br /> j N 119. _ I-- _ — - �y►� --� i _ I <br /> 'T <br /> X I 39- <br /> I ! <br /> 39- -- <br /> 39- <br /> ,--{--llI <br /> iflfl III I VIII ! il !1 N I IIlllll it it {!Illi ,Illi! IIIA I Ili 1 1 IIIIIII I Ii <br /> P <br /> i <br /> A ; APPROVED APPROVED WITH CONDSTION(S) DIBAPPROV9D <br /> SRSTAC3RIENT WISH CGAtUITIONS) DATE <br /> + -lfillifilYll{I�ilflllf Illll i full 1{111 II IIII{ l►li7TTTI.11 -TTM {77TII!III Ti-r=I liNlllilT(f�li ;i:l <br /> I APPLICANT NL"ST PERFORM ALL WORK IN ACCORDANCE KITH SAN klOAOUIN COONTY ORDIN1�Nt'ES, STATH LAN4, AND RCR+F9 AND RpbULA>IONS O£ I <br /> SAN 70AQVIN COUNTY. yNViRONp►FT7TA,, RSALTK DEPARTMENT. OWNER OR LSCENSED A.,,V"tS SICNATURE CERTIFIES TRZ POLLOWIW; "I CERTIFY I <br /> I THAT IN THT PERFORNANC! OF TIM WORK FOR WMICI THIS FV-MIT IS ISSUED, I SKU-1 NO ItiMPLOY ANY PERSON IN 9UCA A MANNr^-R AS TO <br /> I BECOME $VWECT TO WORIKF ,s COMPENSATION LAWS OF CA l"ItNIA.• CONTRACtOR'6 AIR.INO OR SLBCONTRACPINO $ICiNATURE CB74TiFIs3 'THS { <br /> { FOLLOWWO! Of CERTIFY THAT IN THV PERFORMANCE OF TME WORK FOR w"CH TATS PERMIT IS ISSUED, I SMALL EMPLOY PERSONS BUBJfiCT TO <br /> I WORKER'S COMPENSATION LAWS OF CALIFORNIA.• { <br /> I <br /> TITLE C�T�!f' w_ DATE •rj '-o�ca I <br /> APPI,ICAN'�'S BIGYATURE= � <br /> i I <br /> !--- - ----------------• - -- ....-- - -....-----.... - -..... --- - -- -_....-------- ..__....-- ------- ----- - - --- <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit paymen <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 /> NamAddress&&;( Phone <br /> Signature �- <br /> EH230038 <br /> (revised 1/31102) <br />