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• • SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3PD 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 REPAIRIRETROFIT _UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT +________________________________________________________________________________________________________________ _. I I EPA SIM If I PROJECT NNTACT & TELEPHONE # I 1 +______________________ ______________________________________________________________________ -- ________I 1 F I FACILITY NAME uQ, _ _^ L_______________________ P�� # 7-5-4* L •" (rf lull_---------- ---- _,Rdf IA +__________________ _ _ _ __ ___ I C I ADDRESS 4(d)^ BB ///��' B V I +______________________________Y_?__ _ ____y_______ ____________________________________________________________________I L I CROSS STREET / I I +______________________________ ___________________________________________________________________ i T OWNER/OPERATOR I PHONE # I Y 1 ! � _i ------------------- ----- -----------------------t--�1_-747_-S4¢2- ---i -------------------------------- � C I CONTRACNR NANB 14V DQ^rAp &A/ _ _ _ �9W _ I PHONE #(�//'i. e�'�!J__� I N CONTRACNR ADDRESS /�//y� J&X on-2at S6, t/I'✓�� CA LIC # --yy/_Q� CLASS a_ 6,J`J I IT +_____________________YY__Y________________________________`_'_l _______ __r____�7__3�___________K__ ----- ______I I R I INSURER i NORK.COMP.# �/ 1 —E�a• lcv�7__�ivs_ +-------------------3- IA I____________ ______________ __ ___________ -7 IC I onEEt INFORMATION /�✓/�O IT +___________________________________________________________ _____________+___ __________________I 1 0 1 I PHONE # IR +------------------------------------------------------------------------------------+ ------------- I I I I PHONE # I +---IIIIIIIIIIIIIIIiilllltlllllllllt------------------------------------------------------- ---------------I TANK ID# I TANK SIZE CHEXICALS SPORED I DATE USf INSTALLED 39- 1 A 1 39- N 39- 9-N139- I I IK139- 39-_ 39- I -""IIIIIIIIIIillllllllllllllllllllllllllllllllllllllll IIIIIIIIIIIIIIIIIIIIIIIIIIII�IIIIIIIilllllllllllllllllllllllllllllllllllll jL j _APPROVED PROVED WITH NNDITION(S)� DISAPPROVED I I A1 EV `` _\ TT CHMENf WITH CONDITIONS) $ OS I M I PLAN REVIEWERS NAME 1 Kf•+!J SMMIS+___IIIIIIIIIIIIIIIIIIIIIIIIIilllllliilllillilllllllllllllllllllllllllllllllllllllllllllllllillllllllll VIII 111111111111111111111 I APPLICANT MUST PERFORM ALL WORK IN ACNROANCB NITN SAN JOAgUIN NUNfY OEDIIIANCES, STATE LAMS, AND RVLES AND AEGUTATIONS OF I SAN JOAQUIN NIMTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES TME FOLITPrlING: "I CERTIFY THAT IN TME PERIVRI4AIRCE OF THE WORK POR WHICH THIS PERMIT IS ISSUED, I SNAIL NOT EMP ANY PERSON IN SUCH A NANNER AS TO I I BENNE SUBJECT TO WORKER'S O,NIENSATION LANS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBNNTRACTING SIGNATURE CERTIFIES THE FOL ING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK POR WHICH THIS PERMIT IS ISSUED, I SHALL EMPU PERSONS SUBJECT TO I I Mp R'S CNNFENSATION LAWS OF CALIFORNIA.' I I I I 1 Aeel.xcANt's sIa'mTNRs: TxTLe &/Xi&4�hl DATE 92•11'O S�----------------------------------------------------------------------------------------------------------------------------------- I 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 /Mda- VLNigNIzz Address PO Phone#j�d- ZOS-1537 i