Laserfiche WebLink
-SAN JOAQUIN COUNTY , <br /> ENVIRONMENTAL H L T'H DEPARTMENT . <br /> 304 E WEBER AVE.3RD FLOOR. <br /> STOCKTON.CA 85202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT.OR PIPING REPAIR PERMIT <br /> THIS PERMIT.EXPIRES 90 DAPS FROM TMEAPPROVAL DATE. OO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> __TANKRETROFIT PIPINGREPAIRlRETROFIT_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +-----$pA sYTS.# ----r---------------r------.....6-PROJECT CO►1TACT &TELEPHONE ___- ---- <br /> i F + ;----------ME - . " ----- -------= -- -- - - ------------------------1 <br /> ACXLZTY <br /> , <br /> A+...------------------------------------� w---------------------------------------------------- <br /> .0 , AD4ne5a Aye ' .. <br /> L +CROSS STREET __ y=...... _- _-_ .M� -�-___ `- ---_('__ _ -_-_-. ..----------------------------------i <br /> 1. <br /> - <br /> iPHONE <br /> T ------OPERATOR-----�- - --------------- . _--------------------------------------i------ # - <br /> .....-----=-- U1r(�tA---_ -_^�f_ +----- .___ry-�----� ------------I <br /> C + CMfTRACTOR RAM^ c y'[Q S �e 5 y sVy`s { <br /> PHONE <br /> V 0l J" <br /> i0 ------------- spa ____ __ .ft .( i /_S_a_�__e......______w__.�.9..f.�.. ..__,®_____ <br /> N cOxxaACTOR ADDRESS(J\_/:a„ P�A----- ^-�SQC�_/`�(0 l�1 q� I CA LIC 0__?�J I R 4 1 cl"9§ic/Q���e�44g Z({•/C, <br /> { R 1 IssasSR Ine -. slvv `1FYY '�Y . 5 � `3.s_.: 1 _ <br /> 1 C 1 OTHER INFORMATION 1 i <br /> IT a. ----------------------------------------- ---= —........a.----------_---- ---------------------...i <br /> 0 1 1 PRONE 4 i <br /> Ra------ ---------------------------------------------- -----------..........,.—PHONE--------------------—----- - <br /> +.._;)iitlilt{S1t{1i11{{1t11{S1ilI;1----------- ---------------------------------------^-------- ---------_....._•-1 <br /> f { TAM 10 # ; TIM SIZE CHEMICALS STQ= CVRRSliTLY/PREnOUSLY ; DATE UST INSTALLED { <br /> 1 i 3s• 1 { 1 t <br /> 1 T <br /> A 3P- <br /> 30- <br /> 30. <br /> 9`39-39• <br /> ,r <br /> r,t'rr{,{1„ {,I i1,iIllll li 1{i{lfir 1"II.f{{,I{rt{f ii, 1711{iiI{t{t{t„rri..� <br /> P I 1 <br /> i L i APPROVED WITH CO=TIOM( DISAPPROVED { <br /> :.A I ATTACM42NT MITA CCNOITICSQE) <br /> ! N PLAN {?EVIEWSRS;N$MB DATE <br /> { <br /> APPLICANT MRST.PERF ORK IN ACC CEN K BAN 3'0AGOIN COUNTY ORDINANC€6, STATE LAWS, AND RULES AND RZG7LATI1;= OF 1 <br /> SAN JOAQOIN CO=TY, ENVIRONMENTAL FiCAxTN OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FQLLOWINQ: 'I CERTIFY <br /> TS <br /> T= IM E QERFORMANCS OF THE WORK FOR WHICH THIS VERMXT IS ISSUED, I"SHALL NOT EMPLOY ANY PERSON YN SUCH A MANNER A:TO ; <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAKE OF CAt,IFORNIA.' CONTRACTOR'S HIRING OR SUBCCFTRACTINO SIGNATORE.CERTIFIe5 Tux ; <br /> FOLLOWING: "I'CERTIFY THAT IN TNS PMORMANCE OF THE WORK FOR WHICH THIS PERMIT xs ISSUED, I SHAUL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATICN LAKE OS CALIFORNIA," i <br /> 1 <br /> { <br /> j, innTTn117mrn nTrnlinM1.1, TT1TI'R ?11i <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 32yUCLP-7 �j�ddre' ss (03C) ( t)i vm Aoe,�s e®S�I,one# q019 45 0038 <br /> Signature , <br /> EH230038 ` �- <br /> (revised i/31/OZ) <br /> 3. <br />