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OCT-07-2003 TUE 10:59 AM GILTLER RYAN FAX NO. 7JJ93218 P, 03 <br /> 01/25/2002 10:05 2094IW33 FIFTH FLOOR PAGE 02 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 Iz WEBER AVE <br /> STOCKTON,GA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING RVAIR PERMIT <br /> THIS PERMIT EXPIRE$90 DAYS FROM THE APPROVAL.DATE, 00 NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> 1 F `PIPING REPAIR/R <br /> ETROFIT <br /> ............ <br /> 1 • .... _------------ 'i ------------------ <br /> - —UNDER DISPENSER CONTAINMETNTREPAIR/RE-CROPIT <br /> --- -"----,..............88AS]7E AA� a TBI$P3N8 a <br /> ..................................... ..... . w _.„ .-... .. <br /> .-------------- <br /> T <br /> 7 . <br /> .... <br /> rAMOS.FACILITY NAME _Z97_ <br /> -- - - <br /> L 1 CRocs 9rR6E7 --�..��- L.rf�....C�s��.�P...--------.. <br /> Ir oWn io xAron -----•-••-------------------------------- -------- ..........--------------- -------------— -----,.... I <br /> Y •}+. :..Q�.7t.. !Ss _.o.t�_ i PHONE 11 //�� ��rrQQ <br /> I'R <br /> C I CONTRACTOR NAMFi Q �,,( --"••___._ --"...,__--y_-- C�. +IC+_� S'l;W�.,,-_....•--•-•----S�sal _F �I I PFIOxE 0ITI0'-•---• -.......------ �-��.�s�to_I CONTRACTOR HDDA= -'- <br /> + ..... --- . . _ ��•! IusvW:ER - ------------------------- <br /> IAI <br /> }.----------------•........._ I WORF.CgMPAI <br /> I C I OTK" INPORHATION .- . .. . •, <br /> Ta - - ------------------•. I <br /> .....- 1 <br /> R r........----•-... ................... I PHONG 0 <br /> .... - -....- .... ., f <br /> {- 11}1111111r11x}Io11111lIII11i1 ( PHONE <br /> . . . .... . . ....• _I•....- <br /> T A: TAN1f S ZE i CY I`>YCAL9 9TOR CL7RRENTLY/8>ZfiVI0U8LY MITE U$T INST)4L= <br /> A d9- <br /> Ni J 39- <br /> 3 9 <br /> 9-39 I <br /> 19r <br /> 99- <br /> l-p-11(11 I ,Ili ,1111 1, !II III ill11 1111!11 I , Ililllllllfll-IIIIlflllllll ii 1 I-Ti <br /> I L ` x>ppfiO�sD APPRDVRO WITH CORCDITION(S} DIyipSROVSD <br /> A I (S2t ATTACRNMUT GWTTR CONDITIONS}N FLAN REYIEWSRS NAME DAT£ <br /> 111111111111111;{III 11111111 I Il11111111 1!111111 Ilflllll I i 1111!11 II lull 11111111! <br /> SANJ0>O MUST pTy, D ALL WORK IN ACCOWtLWNC4 WITH SAN JOAQUZN COLNTY OADINAWCes, ,"TATE LAWS. xtm RULES AND xgm.%AT;ONS OF <br /> BESAN SOAQtIIN Cp'($rrY, ENVIRONMENTAL REALT'31 =PARTMFINR, OWER OR LIC&NWBED AEENV$ SIGNATURL CERTIFIES TRE FOLLOWING: °I CERTIF7TWR ! <br /> GOItlBN$fJD]CC'I'RSOR QRKBROS COMPENSATION LAWS OFol M'rCn F CAI,IPORNITAIS CONTAA,:TgR'9 HIRjNG OR SUBCQNTRA.CTLOY ANY ON6ISIG2Jl,TURe p>:KSr0NE <br /> FOLLOWING= "I CERTIFY TFiA7 Ty THE L,,,, <br /> XzJ9CE OF THE WORK FOR WHICH THIS pZgMIT IS TI%=D, I SHALL EMPLOY AM&oNS SUBJECTNORMA'$ COMPER-SATION LARf1IA.” <br /> �~W t W c.. f <br /> APPLICANT'S SIGMA <br /> .......... <br /> .------- <br /> ---- TITLE (CLAi Ll,A�1111mJ.IIB AArs <br /> .. ...............................--..•..-•••---,...----------------- ...----••---•- ---► <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 Address Phone number <br /> Signature <br /> EH230036 <br /> 1 <br /> IAN 25 10 9: 20 2Q94683433 PAGE.002 <br />