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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3RD 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: J TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT � I�fS>p4QcA-`p +--------------------------------------------------------------------------------------------------- --------------- EPA SITE # ; PROJECT CONTACT 6 TELEPHONE # +---------------------------------------------------------------------------- -�tia�---� /��pp�� /��le`A ��p ^ F ; FACILITY NAME .2__ S ------------------------------PHONE-#- --- 1--- _I 1�O�11------- a A +-- 'S� C � ADDRESS ' S�-_(r�I jnA I : ADDRESS -------- -- Qo`�! ------------------------------I L ; CROSS STREET ' I +---------------------------------------------------------------------------------------------------------------------------; r ' T ; OWNER/OPERATOR ' , ; PHONE Y : Louts CZ U A�V cl 5=6 -------------- aoa-s�I- o `f b---- ---+-------------------------------- -------------+----------------- - ------- C ; CONTRACTOR-NAME ,p,,�` .,}.�/��A �,`e tA,5 •1 /' ; PHONE # C�O �...�A o.3.may" T +------------------- S.1�Y _1 Si.Y_Y'---TIL.Y 9k-5 `eY�S,<---------------------------- --------- -'SL----'. ' N , CONTRACTOR ADDRESS-k 1�0 .\L�� Poe- CA LIC #4�S I '�4 ;.CLASS R 14ts 14y{•Z ac V r �1 E�QI U R ; INSURER k1c6 A.i--- r'_S�` -- -WA-F --------------------M 1 WORK.COMP.#_5 --- v_------------ ' A ;--------------- -' --- -- - +------------------ C ; OTHER INFORMATION ' T +--------------------------------------------------------------------------------- 0 ; PHONE # ' R +------------------------------------------------------------------------------------+-----_ ----------------------_-_� PHONE # rrr�rrr�rr��rrrr�I� ---------------------------------------------------------------------------------------------- r1r1r�1 1TANKI ID #1"1"11'1 TANK SIZE ; CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED 39- T ; 39- A ; 39- N 394 4 - K 39- 39- 39- +--- �rr1l�i�i�iiii�,rrrr111r1rr rri1111i��iri lir/i�i��rl ii��rilrrrll iii��llrrrrli;irll;;i rllr�r�l��i�rr111 rr rirlrr rri� P L ( APPROVED APPROVED WITH CONDITIONS) DISAPPROVED A ; (SEE ATTACHMENT WITH CONDITIONS) N ; PLAN REVIEWERS NAME DATE .��...... APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 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 TQ WORKER'S COMPENSATION LAWS, OF CALIFORNIA:". CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE ; FOLLOWING: "I CERTIFY THAT IN THEPERFORMANCEOF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I.SHALL.EMPLOY.PERSONS. SUBJECT TQ WORKER'S COMPENSATION LAWS OF CALIFORNIA." 'I /�/'� APPLICANT'S SIGNATURE: J- -�"�'V � TITLE�N'� tasc� 6L{,WEJDATE +------------------------------------------------------------------------------------------------------------- ---------__--+ 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. NameMARnNy Wetrt11 ddress �� b ( Sal,�� Phone# 6(- �w� V EVIL 1419e. Signature r � �� 1�1,�� U • l�" EH230038 (revised 1/31/02) 1