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USAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3"n FLOOR . <br />STOCKTON. CA 9x`202 <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 SHADEO AREAS. INDICATE PERMIT TYPE BELOW. <br />-_TANK RETROFIT PIPING REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIRIRETROPM <br />----------- -- --------------------------------------- --`--------------_..^.--------------------- ---------------- --+ <br />1 !.VPA SITZ #I PROJECT COmTAcr & TELEPHCNE # { <br />' P +-FACFLITY NAME lJdl'i_JJVCL� `T-�--j- -�i------^'----'--n-'---- ----�'I_PrH7aNE_#_ =.L. ., 36_-_0 <br />---- 3'7�?.--1 <br />ADARES- __--�S Cl-. p -I------ E -__I._ S _�.....1 I ' <br />I. L { CROSS ------ -� lft�6l �✓ <br />I 1 --------------- u" ---- __ <br />F 1 OWUWR/OPERATOR ♦ �})[ ,.I� I PHONE # -2-01 <br />., C (� r Q �j O ^�,^ r� .� }\ , <br />-__ ___----_ ----_--__r <br />C ; _ COITRACTOR 19AME C „y � Q_ J"\ 1.�1A� 5 St1�+�i.S 1 PHONE #k-�- 1 <br />1 0 +--------=--=------ -- n -- ------------------------------- ,j/---- ---- - ^- <br />N CONTRACTOR ADDRESST\_/`.,q4_itra�0 _�SL QCj 1`�._:- CA LIC -#-%�QS�^-'------ Ct,AbSlC( 11�rV�/•I� _'IG <br />I T +----------c------L--y_ `_ S! �{Y =7 __ - -j� -- _ <br />i ft i ;NBDRER O �7 lD CQ �ViS ��� i TP.—til /A g aZcy/� <br />i C i OTHER INFORMATION <br />' <br />T------------------------------ ------------- <br />O -------- 1 BROKE iF - I <br />' R a------- --------^----------------------------- ........... <br />.. 1 PHONE (F . <br />i----------- ,. ------------------------------ -_--_- <br />ID # 1 MONK SIZE - =MICALS STQMP CW6=TLY/PREVIODELY 1 DATE UST INSTALLED 1 <br />T 2g- - <br />i A 1 39- <br />i N i 29- 1� r <br />- <br />1 <br />1 L 1 _ APPROVED APPROVED WIT3 C05M%T2CN(S) DISAPPROVED <br />(SEE ATTACHMENT WITH CONVITIWS) n I <br />1 N i PLAN REVImmkS N$ME `/_�. WC, DATE 10-2—0-0�j <br />----IIIIIr�11111.1Ii.)Illiti.�rrr.rr r.. .......r rr�r VIII,r.;Il,r..�illrrrlllr11l11irrI1llrrrrrrrr .r .....�.r�.r�rI11 <br />APPLICANT MUST. PERFORM ALL WCOUC IN ACCORDANCE WITR $AN D'OAQU1m COUNTY ORDINANCE6, STATE LAWS, Amo RULEb AND REGULATIONS op <br />.SAN TQAQVZN COLVTY, ENVIRONMENTAL F➢EALTH DEPARTMENT. OWNER OR LICE2G.10 AGENT'S SIGNATURE CERTIFIES TIM FOLLOWING: 'I CERTIFY <br />TRAT IN THE PERFORMANCE OF THE WORM: FOR WRICH THIS PERMIT 19 ISSUED, I SHALL NOT EMPLOY ANY PER.sad IN SUCH A MANNER AS TO I <br />RECOME SUBJECT To WORKER'S COMPENSATION LANE OF CALIFORNIA.' CONTRACTOR'S AIRING OR SUBCONTRACTING SIGNATURE CERTIFIES TIM <br />FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TRIS PERMIT is ISEGED, I SHALL EMPLOY PERSONS S%XJECT TO i <br />KE <br />WORR'S COMPENSATICN LAWS OF CALIFORNIA." <br />1 <br />1 <br />i <br />j, 1nn7.Tn111MIrl nTrMD M1n3i T(TLR ?>iI <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br />coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br />owner, the party must acknowledge this responsibility for the billing by signature and date below. <br />TIS lix <br />Name CCP_Si3b"Address 00 aoivo A�-,Sgt. M Phone# '�0$-aB-60S� <br />Signature .:JL� L? - ` ,(_4,L itrC?t=:C'-1 <br />EH230038 <br />(revised 1131/02) <br />