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02/25/2005 16:37 2094683433 FIFTH FLOOR PAGE 03 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE,340 FLOOR STOCKTON,CA 9$202 APPLICATION FOR UNDERGROUNDTANK RETROFIT,OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: TANK RETROFIT PIPING REPAIRlRETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETRORT --------------------••-•-----------------...---------------•--------------------.-..---..---------------- + I I EPA SITE -0 1 4ROJECT CONTACT f. TEL£PRONE M ------------------------------ � T ---------------------------- mut I, -�'/------- I F I FACILITY NAME LALs ----- a -- Z-7 -- 'L I It ADDRHs- 'L'Z---- - N--- T1 E -�D-- ---------------------------------------------------------.- .------� I L I CROSS STREET 1 2 •_____________________ ..------___---.' PHONE M { s T OVUER/OPERATOR ..... L'�,JT. ------------------------------------------------I 10 / --------------- I - - -- ' al,, � Y { _, I C I CONTRACTOR NAME A (�( C 1-f- I PRONE p ---I IO •--'--------.....----------------------••-�•_-�----D-----_......-'-----;'CA LIC•9------__---------'-I CLASS--------"------' i I N 1 CONTRACTOR ADDRESS 1?7 v I c�Ci S-- >g -------_43-�'-- ----------------------------------- ------------------- TI ( •------------- -------------------- - I WORK.COMP.f I -7 70 7 ZXO j- I R I ZNMER ---'---------- ------ -- C OTHER INFORMATION ------------------------ PHONE I ; PRONE Y * - - tII111111111IIITp11�1lIIIllllll�------.-------------------------------------.----- -- - --------- -- -- - - ........ - 1 TPJM TANX SL2E I CRfiHICALS STORISJ CIAlRENTLY/PREVIOUSLY ( DATE UST INSSALLED , { 39- 29- N 9'39-N I 39- 1 I 1 I R I 39- I ; I 39-39- I +___1111111 111 11 I . 11l11111I17„=illyl It 111111) 11 Iiii,ltlll{Illlt{i ll'Illilllllllltttltliii I P I , t I L 1 P AP v WI TION ) ^ DISA4PROVED T A I tux A TH I NS► DATE 9 I PLAN REVIEWERS VVIE ---IIIIIIIIIIl11111114t11 � ( � �,� � Ilt � 111.1111 � „IIIIIII:II � � � I{IIIIIIIIIIIIII� I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNlY ORDINANCES, STATE LAWS, AND RUT." AND REGULATIS Of , SAN JOAQUZN COUNTY, ENVIRONMENTAL W.ALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE TOLLOWING: "I CERTIFY { ' A MANNER AS TO THAT IN THE PERFORMANCE OF THE WORK FOR WY.ICX THI5 FERMI? 26 ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH I BSE SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUED, I SHML SIGNATURE CERTIFIES THE I FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERK' T IS ISSUED, I 9NA,LL EMPLOY PERSON? SUBJECT TO I WORMERtS COMPENSATION LAWS Of CALIFORNIA.- , ip ♦�� APPLICANT'S SIGNATURE: TITLE V"– DATE UR I •--------------------•---•-••----------------•--• ---------------- __.....---------------- -�- - ----- BILLING INFORMATION: Indicate the responsible party to be billed for additional EHL) staff time expended beyond permit paymen- coverage per tank. If the party designated below is different than the permit applicant, e.g. propertj owner, the party must acknowledge this responsibility for the billing by signature and date below. Name 744( Address 0"7S 17 _Phone# Signature EH230038 (revised 1/31/02) 1 .