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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3R0 FLOOR STOCKTON,CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: _TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT +---------------------------------------------------------------------------------------------------------------------------------+ I EPA SITE # I PROJECT CONTACT & TELEPHONE # i +------------------------------------ ---------------------- --I ------------------------------------------------------------- --- F I FACILITY NAME - - - � I PHONE # A +--- ---- -----'------------------------i ------------------------------ , `�p ,yam/y � I C I ADDRESS `- T (/W " T! F 1 ------------------------------- I +------- - --- ---------- - - - ------------ -------- ----------------- I - - I L I CROSS STREET C f �- r - ---- ------=- -�= '- -------------------------------------------- ---------- PHONE T I OWNER/OPERATOR �} ^-- - - - - ,I I C I CONTRACTOR NAME 4C � 1 R---/' /�� I PHONE # I0 +--------------------- -----------------------------------------------------------------------------i N I CONTRACTOR ADDRESS �t�j S�6 �QSLS j I CA LIC # �j�( I CLASS ----- T +--------- WORK.COMP.# I jp '^f ----- - o R I INSURER A" — i ---- /�-'�!y C.J✓C_f�K-�`_J� I 1 A I------------------------- -- -----------+-------------- -------- ---i C I OTHER INFORMATION I I O i----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- IPHONE--#--------------------------------i -------------------------- ----------+------ ---------------------------------I R +------------------------------- ------- I PHONE-# ---�IIIIIIIIIIIIIIIIIIIIIII�------------------------------------------- TANKID #{ RENTLY/PREVIOUS ----------------- -----------i---------------- ----i TANK SIZE I CHEMICALS STORED TLY I DATE UST INSTALLED I I r IT139 T I I J6 I I A 139- N I 39- FnI I K139- I I I I 139-39- I I P 11111111111111111111111111111111{Iii{{lilll 1111illlll{Ililll{Illlllllllli{{1111{ IIIIIIIIIIIII{1i11111 111HIM] I IIII MIMI L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED A i SEE ATTACHMENT WITH CONDITIONS) DATE I N I PLAN REVIEWERS NAME +___11111111111111111111111111111 Ili I{{11111 I{IIIIIIII IIIIIIIiiIIII IIIIIIIIII{Ii111lIIIIIIIIIH IIIII II111 11111111ii111iii � I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF 1 SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY I THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." I � I APPLICANT'S SIGNATURE: TITLE DATE I -------- BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. Name C 11(4 f 4mg Address's A Lo -�G '��T L �rt �� Phone Signature EH230038 TO Sc N�n►��-E T�,Tt oF- T1fiE (revised 1/31/02) ` T 0"AS (N A-Dv 4N� 7 c,roR 5 �4'r S y g 1