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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT 9 <br />304 E WEBER AVE, &ID FLOOR <br />STOCKTON, CA 02 C11� <br />�0 <br />�,,��I' �S <br />952 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELO (iis <br />—TANK RETROFIT __PIPING REPAIRIRETROFIT _UNDER DISPENSER CONTAINMENT REPAIRIRETROFrr <br />------------•---------------• -----------^------------------------------ ----------'--------•----------- <br />I I EPA SIT-- 9 1 PRc,Tscr cI)IIi7+cr r TELBPRONR N 11 <br />aI F LAY �k93 _ Lon. •----------------------- ---I_D�rE � �4_ �•"t �/ �S2u <br />1--------------------- - --- --- --- -- 1 <br />I L I CRDS6 STRSST I <br />II+---•---------------•---------------•-----------•-----------------••------•-------••---------------•------------------------•-I <br />I T I OIWM/OPERATOR I PUONE # I <br />IYI I I <br />--------------------------------------------------- 1* •--------------' --------------- - ----------------------------------------- <br />C <br />------------------------••-------------C I Wa A=OR W6AZ T 1 PBONS p I <br />ID ___ --- --------------------------------- II II I -- (�-------- .- ------ <br />CO-- ADD- LIC 7y3i o• !-Z�O�~ <br />------�•-----! -- - --___ <br />R <br />I �z--R Go I 'RORY..CaW.4 C 3y <br />'__� <br />41 <br />tiFI <br />--n>__C �_.. --------------- ._ <br />1 C I anm ICDDLalcm .( I <br />I T -------------------------------------------- _-------------------------------------- •---------------------------------------- <br />I <br />1 0 1 i Pt1= s I <br />IR----------•------------------•--------------•-----------------------------------•----•-----------••---------- ----------I <br />I PRONS 0 I <br />+ IIIIIIIIIIIIII111111111111111111----•---_--_---_-------------------------_------_-..-____________------1 <br />I TACK ID H I TANK SIZE I CIEMICAIS =RED Ct1RRHMY/MVICUSLY I OA= DST XM;TALLED 1 <br />I 139- I I I I <br />I T L 39-_ <br />I I I i <br />lAl3�- I I I 1 <br />1139• I I I 1 <br />IK139- I I I 1 <br />I 139• I I I I <br />I 133- I I I I <br />LZPF.RCIVIED <br />L I HITR C'ONDMCM (S) DISAPPROVED I <br />A I (MC -Ma HLTH OGWOI120N8) \ I <br />I Y 1 PLAN REVIS ms tUN PATE JJJ 1 <br />„__.illlllililllillllllillll II IIIIIIIIIIIIIIIIIII 111IIIIIIIIIIIIIIIIIIIIIII1111111111111111111111 1111111 111111111111111 <br />I I <br />1 ILP?LlrAvM MIST PERIGYCQ ALL WORK IN ACCGRDANCE WITH SAN JOAq= COU= ORDINANCeS, =TE LAH ANO RDLES AND R=9ATYONS OF I <br />1 <br />MN JOAO= COUNTY, ENVI>tCt*M?i'AI. HHALTH DZP111YR.R•2rr. Cn7NER OR LICENSED .;CMr'S SIGMNTURE C'ERTIFIE6 THE FOLLOWINO: "I =TIFY 1 <br />v3MR:4MCE OP TIM YR3RK PGR V4UCR Tsar PERMIT IS ISSUED. I SHALL NOT MULOY ANY PERSON IN SUCH A MR4MR, AS TO I <br />P -DC-- ,M SUWECr TO WORKER'S CO6II L-MTICN LAWS OF CALIFORNIA.- CONI; hCPOR' S R n;G OA SUBCONTRA=10 SIQTA7= CCRTIPIRS THE I <br />I ?OUO rIM: It CERTIFY 'MAT IN THE PGRFORM= OF THE WORK FOR WHICH THIS Vmmn IS ISSUED, I EUJZ EMPLOY PERSONS SUBIEcr TO I <br />=TV—SATION LAWS OF CALIFORNIA." <br />I I <br />I <br />1 .V'DLICANT'6 6LGi`DiTORE: TIRE <br />I I <br />4-- ----------------•------•----------•-------------.., ---------------.•--•----------•---------------•---- ------------ <br />BILLING INFORMATION: <br />ViAT IN <br />WORYM-M'6 <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit paym nt <br />coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, <br />the party must acknowledge this, responsibility for the billing by signature and date below. <br />Name Address Phone # <br />1 <br />