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.-SAN JOAQUIN COUNTY , <br />ENVIRONMENTAL, HEALTH DEPARTMENT <br />304 E WEBER AVE, 3"' FLOOR . <br />STOCKTON. CA 95202 <br />APPLICATION FOR UNQERGROUND TANK RETROFIT. OR PIPING REPAIR PERMIT <br />THIS PERMIT F-xposs aoDAYS FROM TMEAPPROVAL DATE, DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW' <br />•_TANK RETROFIT PIPING REPAIRIRETROFIT —UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />*------.--.........-------------.._.----------------=-------------- + <br />t ;•VPA ZXTZ #Q' ; PROJECT CQMTACr & TELEPHONE # 4 ? � �•i[� i <br />I F + FAC7LETY NAME �� C NV -- ----__..------^------�'PE., s _.Fi `�iY� __ J 1 �"----i <br />I ; CROSS STREET _0t�� <br />II b- -- -_� q_ __--------- --------------------------­- ------ -^--_- 1 <br />I T { .OWtPIOt/0912RATOR I PHONE # ; <br />I x I C_.�_A_-c�v�c� V, . I _L - $3b —9'4 ,-1... .i <br />1---+----- -=---- --------------•r---- -----------^--------..---"^---------------------,----"]-- --------- <br />! C CaY R3ICTOR 17AM8 � 1 � d �[1S LI S j' tLt S 1 -PROM <br />---- R } �{ �- • cQ%3 0- I <br />I0 +_------- ---�--- . _- ..�.1 � - (-�---I------- .------- .__- _ _(_� ......,.Q..._. <br />I N : CONTRACTOR ADDRESS f\ f;ti gtiso�a i�A j- J0.fAt,�Q !_�9 �6 1 `�- I CA LIC #- . ��.-- --. tzASSp��B'�i�tl D:-C•S�Y.-:^T.�.� � 1 C <br />RAS 3;N807-ft� �vr _LLB[�t3YW,SdsLil��.. 531 1�r -----------r NORK_C------ <br />C { C+rim INFORMATICN <br />1 0 ------ -------------------------------- -..= PHONE # - <br />----------------------- - ---_.- -----I <br />Rn --------------------- ------------ ---------------- -------------- - <br />PHONE #i <br />++ <br />..-Sr{f;Iliitt�'iSlitti{{i;i{iittt{------------^---------------------------------••_-------------.._...-----------------------i <br />I i TALAR XD # 1 MAI;&SIZE ;CHEMICALS STORM CDR12HTLY/PREVIOUSLY 1 DATE OST INSTALLSO 1 <br />I T t 39- i <br />A ' 3P- <br />19- <br />39- <br />31- <br />+ <br />9-39-39-+ <br />1 L I ARPROVED APPROVED WITS COSMtTlON(S) PISAPPROVBD <br />1 A 1 e 1. ATTACHMZNT WITH CMMXTIMgS) <br />i N PLAN I¢EpI—ki X*R 1 /V IV �n DATE I 0 - Zv v <br />1" 't'11 2' " " IIt" ", " I •"1111 '11' 'i' 't <br />----16if{illi`{iL1;;:tr;i „ ri, � ,Itl{t:i••:;li.,t �.i,tl��t1„ •:It:fi111.,rit{�Iti 1111•, li. ,1.•4.l:. .;flit{it. ...i <br />i• <br />i. APPLICANT MUST. PERFORM ALL NOR$ IN ACCORDANCE BITX CAN 0=01H COUNTY ORDINMCM, STATE LAWS, ABD RULES AND REQUIATIONS OF <br />1 SAN "As VIN Cado"Y, ENVIRONMENTAL EMLTH OEPAaTMENr. OWNER OR LXCEDIAM AGENT'S SIGNATORE IFIES THE FOLLORINB: -I CERTEFY <br />THAT IN THE RgRFQFJ=C:: OF TEM WORX FOR WHICH T=-, DEFMYM IS ISSUED, I SM41, NOT EMPLOY ANY PERSC01K SUCH A MANNER AS TO I <br />BECOME SIM CT TO WOUrIA'ta COMPENSATION LAMS OF CAY.IFORNIA." CONTRACFCa'S HIRING OR SDBCONTRACTINO SIGNATORE,CERTIF%ES TIM ; <br />POLLOWTUd., "I CERTIFY THAT IN 74M PBR20RMANCE OF TWS WORK FOR WHICH THIS PERMIT TS 1SWED, I SHALL EMPLOY PERSONS SUBJECT TO I <br />6 VORIMR'S COMPENSATICM LAWS OF CALIPORNIA." 1 <br />1 i <br />j, sinnTrnanmrn nTmiurnflMt MW Phil I <br />BILLING iNFORMAnON: <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 tCR_'�t1c�t���ddress l0186 aUA0 ,6tTPhone# '`fig -d-15-663 <br />Signature ` X c- <br />EH2soa38 <br />{revised '1131 /tit} <br />z <br />