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FROM :BSSR, INC FAX NO. :6615882786 Aug. 10 2006 09:00AM P3 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 394 E WESER AVE,3R0 F=R <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PgRMIT <br /> THiS PERMrr EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PEROT TYPE BELOW. <br /> TANK RETROFIT_,-,PIPING REPAIR/RETROFITUNDER DtSPENSER CONTAINMENT REPAIR)RETROFIT <br /> +-------- _.._..__-----`------------------------------------ <br /> ------------------------------------ <br /> ; BMSA SIT$. # I PROJECT CONTACT & TELEPHONE # -__-____�_____-___ <br /> +---------------- ------------ I ----------------------------- --------- <br /> 8 FACILITY NAMLP _ ,yn �-+/ ),1'� ; PHONE # /� <br /> A +.-------- ---- ,�.K Lvsz--—_- ----------------------- - ..-- <br /> , <br /> -� <br /> - <br /> ' C i ADDRE$$ <br /> L ; CROSS STMZZT <br /> + - � ---^---_-~ "----�-�---�----�--- -C-A-. -------`-- #_ ..------'--------_._. <br /> T URNER/OPERATOR )'HONET `t-. <br /> -+ ' - _ -------------------- -.. .-,-------------------- .. ._-_- <br /> 1 C CONTRACTOR NUM SSG„ G PHONE # <br /> _ <br /> ' N TRACTOR ACDRESS _ <br /> ----;i <br /> ' WORK.CDNP.# <br /> C OTHER IMPORMATION <br /> r <br /> 0 1 1 PHONE # <br /> R +-------__ ....... ---------------------------------------------------_--------------+--`-----------------------`------------- <br /> r <br /> 1 PHO M # <br /> -`----------------------`---------------------___------------------------------------------_._ <br /> rrrrrr r <br /> 1 TANK ID 5 ; TANK SIZE CH$MICAT,5 STORED CURRENTLY/PREVIOUSLY 1 DAT! Z$STRLLED , <br /> T 1 39- <br /> _._. <br /> N i 39- A! <br /> K ; 39- s^ <br /> 3$- <br /> r I ' <br /> 39- <br /> +-- <br /> 9_+-- <br /> P-r <br /> L ; APPROVED APPROV=) WITH CONDITIONS) DISAPDROV%13 ; <br /> A (829( (SEE ATTACHMENT WITH CONDITIONS) <br /> N ; PLAN RLVIEMRS NAME SAI. 1V G ZATE lj <br /> rrr.rrr rrriri r <br /> APLICANT ND9T PEPVQRM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATS LAWS, AND.RMZ0 AND iMtrLATxONs OF <br /> ; SAN JOAQUIN COUNTY, ENV'=RONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S arMMTUFX CERTIFIES THE FOLLdWING: "I CERTIFX ; <br /> 1 THAT IN THE PERPORMA)iCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SSALL NOT EMPLOY ANY PERSON TV SUCH A MANNER A$ TO <br /> r BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OP MIFORNIA." CONTRACTOR'S HIRING OR S(ffiCONTLiACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING, "i C> T%n THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TH;$ PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SLISaACT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURES 7 TSTL$ mow' DATE � 6 <br /> +-- <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 0S-12o Phone# <br /> Signature <br /> EH230038 <br /> (revised 9134/42) <br /> 1 <br />