Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3RD FLOOR <br /> STOCKTON,CA 95202 <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 BELOW.' <br /> TANK RETROFIT _PIPING REPAIRfREiROFR UNDER DISPENSERCONTAIINT AIPAMTRORT <br /> ----- -----------------'-_-------------^-PHONON---------PHONON--- <br /> +------- - PHONON <br /> 3 / <br /> EPA SITE: : PRO'TECT -T A� # <br /> . <br /> F ; FACZLI'TY HAMS - ' w—w <br /> _ PBO=# <br /> A+_—__________— _ -•• — -- <br /> ' C ; ADDRESS CROSS <br /> L+ ---___-__ <br /> I <br /> T OPERATOR ; # <br /> C CONTRACTOR NAME - - -� L.0...tom � J 1=y` P #,� j Z�. D <br /> i o+-PHONONPHONON--PHONON--- -�: i — -- --=—r r <br /> '�' <br /> N 1 CONTRACTOR ADDRESS l_`.c'1 \Eiir Sfiu,"I'li�'1 - <br /> R+ INSURERS[ "�, 7 �� �.CO!@.£; <br /> S. / '_ <br /> ' A <br /> i C ; OT116R IIa"�IQiTION __ _ —_� <br /> : T <br /> PH=# <br /> O ' <br /> ' -------^---_---_-_--__—��____--PHONON_PHONON-PHONON-- <br /> R+PHONON--_--_ PHONE# <br /> __PHONON-PHONON----PHONONPHONON-----PHONON-----PHONON---_-PHONON-"—__--__--_ <br /> •&M ; <br /> TANK ID,#, TIM SIZE ; CHS(IICALS STORED CQRRBWIT+Y/PRBVIOOSLX DATE OST IELS17 <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K ; 39- <br /> 39- <br /> 1 39- <br /> P 1 <br /> L 1 APPROVED•• •-Z—PROVED WITH CONDITION is) DISAPPROVED ,�•� <br /> 1 A 1 �j\�� (' (SSB ASTACBN@CT WITH CO7IDITIDNSI `z, <br /> 1 N 1 PLAN REVIEWERS WANE it l OA y �,,L) STH <br /> APPLICANT MOST PERFORK ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAOS, AND ROLES AND REGULATIONS OF <br /> SAN JOAQUIN COD1(TY, SM1112121MBNIAL HEALTH DEPAWIME T1. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE POLIANING: "I CERTIFY <br /> A-WARNER AS TO <br /> THAT DR THE PBRPORIOINfS 7118RORK FOR WHICH THIS PERMIT IS ISW, I SHALL NOT MUWT ANY JIM= IN SOCA <br /> BBCO►m SUBJECT TO WORKER'S CATION LAWS OF CWTRACD7R'S ICIRISG OR SUBCONTRACTING SIGNATURE PIES TEE <br /> FOLLOWING: •I C�tTIFR TWAT IN THE PERPORKNV*O THE WORK MUCH THIS PERMIT IS ISSUED. I SURIL SRPIAX PERSONS SUBJECT TO <br /> NORKSR'S COMPENSATION LAWS CALIPC)RNIA.' <br /> APPLICANT'S STCOiA rsTLE "-"' <br /> --------------- __ -_____ - -------------------------PHONON--- ------------PHONON--- -------------PHONON--+ <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' <br /> ddress 3 � _Phone <br /> os7 <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />