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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 FROMTHE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW. <br />_TANK RETROFIT ✓ PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />+--------------------------------------------------------- <br />; EPA SITE # ; PROJECT CONTACT 6 TELEPHONE # <br />F ; FACILITY NAME f ----------------- <br />I A +-----------------1 1--0—"— PHONE # , <br />C ; ADDRESS <br />C�`,vd/x-v� <br />, <br />L ; CROSS STREET! <br />+--------------- <br />Ll�------------------------------------------ <br />I -------------------- <br />OWNER/OPERATOR <br />'1 PHONE # q <br />Y ` _ °` �� — <br />4 N,p_ � �2 .� f� <br />l/ ----±- <br />; C ; CONTRACTOR NAME -- PHONE # <br />D +-------------------��" S -! WA �� ��_5��1 _�-rx�------------------------- - <br />N ; CONTRACTOR ADDRESS �" O �� x �O ^C /''fes , <br />T +---------- -------���----- ---�—SWI 05_C—'—CA LIC # --33a! --- �5---�----C5i---' <br />— — — -------------- — <br />R ; INSURER `}1}�1yp L/ 1 <br />A ;---------"�_) "�— C ; NARK.----- <br />C ; OTHER INFORMATION <br />T+------------------------------------------------------------------------------------+- <br />;o; <br />; PHONE # <br />R+------------------ <br />; PHONE # <br />TANK ID # TANK SIZE ; CHEMICALS STORED CURRENTLY/ PREVIOUSLY ; DATE UST INSTALLED <br />39— <br />T ; 39— <br />A , 39— <br />N ; 39— <br />K 39- <br />39- <br />39— <br />P <br />L APPROVED APPROVED WITH CONDITION(S-)$ DISAPPROVED <br />' A '(SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS DATE \ <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />; SAN JOAQUIN COUDITY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br />BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIEORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: AIA r <br />TITLE-40/Jjzo�AG O DATE <br />+----------------- -- ------ <br />BILLING INFORMATION: <br />THAT IDI THE <br />WORKER'S <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 owner, <br />the party must acknowledge this responsibility for the billing by signature and date below. <br />Name i�� <br />Addres,� Phone #,Zo9-�, <br />s ��� F �� �% �oti �srros n <br />