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<br /> 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 D�YS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW.
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<br /> TANK RETROFIT_PIPING REPAIRIRETROFIT_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT
<br /> +------------------------------------------------------------------------------------------------ -------------- --- +
<br /> PROJECT CONTACT & TELEPHONE #
<br /> ' I EPA SITE # fL*M4 c(--
<br /> ,
<br /> F I FACILITY NAMEL 0__V5
<br /> C----
<br /> Cz,t 4!� -5-4-O j , PHONE #
<br /> ----- ---------------
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<br /> I C I ADDRESS (5 sa-�-�-.{-, z ------------------------------'
<br /> I L +-CROS---TREE------JdL-C..ka V{�'e� &
<br /> L CROSS STREET '
<br /> ' I +---------------------------------- ------------------------------i
<br /> ,
<br /> ( T I OWNER/OPERATOR I , PHONE #
<br /> I C I CONTRACTOR NAME ��� `=`�ry}� So f� C 1 Tai('�------------------,_PHONE-# jio t-�Q,3 _�W g------'
<br /> i O +------------------- A ------AS= `� -2 �- p�
<br /> N 1 CONTRACTOR ADDRESS V �lwAve- ' CA LIC # q d S1,9I CLASS C
<br /> T +---------------------=$---- ------------------------ ------'-------------------- -------------y- -lot------- Z;
<br /> R INSURER � � - lt� i WORK.COMP.# S1 Q. �3 '
<br /> ��-__ _�S�- - -------------------+- --------------------------------------i
<br /> C I OTHER INFORMATION
<br /> ' T +------------------------------------------------------------------------------------+----------------------------------------I
<br /> 0 I I PHONE #
<br /> ' R +------------------------------------------------------------------------------------+----------------------------------------(
<br /> ,
<br /> I I PHONE #
<br /> ----------------------------------------------------------------------------------------------
<br /> 'TANK'ID'#' TANK SIZE ; CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED
<br /> 39- 1
<br /> I T I 39- _
<br /> I A ; 39-
<br /> N 1 39-
<br /> K 39-
<br /> 39-
<br /> 39-
<br /> +--- ,,,,,,„ ,,,,,,,,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,i „ III' 111
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<br /> L APPROVED _W'�”APPROVED WITH CONDITION(S) DISAPPROVED I
<br /> A ; (SEE ATTACMNT Wf CONDITIONS) i
<br /> I N i PLAN REVIEWERS NAME ���� AVL—� L /V�ia�- DATE "�Ja 6
<br /> ,,,,,,:1:::lm: ii 1 i i i,,,,,,,,,,,,ii 11!:;:„ 111
<br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF
<br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY
<br /> 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
<br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." 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 I
<br /> I WORKER'S COMPENSATION LAWS OF CALIFORNIA."
<br /> i
<br /> I APPLICANT'S SIGNATURE: 1 aaLx+ /�"'�"— TITLE v-µa.�i, lJ ICU►�DATE `�� )
<br /> /L
<br /> +-----------------------—----------------------------------------------------------------------------------------------------+
<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 I�.t4tZt'11�( V° U.���Z4kkl> ddress w✓ 6k; wt xlel S S, �� ; �f J l��Phone # 4L S'�1 �C C 7
<br /> Signature
<br /> EH230038
<br /> (revised 1/31/02)
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