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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3R0 FLOOR <br /> STOCKTON.CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> _TANK RETROFIT PIPING REPAIRIRETROFIT_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> ______ ___________ ________________ _ <br /> _ _______________________ ___________ •� '^n <br /> EPA SITE # 1 PROJECT CONTACT A TELEPHONE #�bh t � �� /tI 1 <br /> {_________ ______________________________________________________________ _______________________ _ _____________Q___________, <br /> F FACILITY NAME /`Q- _U �_________ ____________________PHONE_-___vY �� �_�+_a --___� <br /> A {_--------______ _ _ _ <br /> C ADDRESS `ld � _ / 11 'gyp <br /> I +_____________ - _ _ ___________________________________________________ <br /> L I CROSS STREET <br /> J ' <br /> PHONE # <br /> T 1 OWNER/OPERATOR 1 e l ------------------------------------------ <br /> - -_ - \ ___________i-PHONE # -100- -1791 v��F_______ <br /> C CONTRACTOR NAME _____________ CA LIC_#___ WORR.COMP.# C 7E ____�_! <br /> , 'J <br /> 1 0 +____________________ ______ ____- / Gd - <br /> I N ! CONTRACTOR ADDRESS 1 {n 1- `��_�Y�___ ___ �A�L Q_(_____________ ���t <br /> SC»ASr% , <br /> R INSURER Sy,_#�•#- \ 1[-"33_ L-1�D1J <br /> A1________________________ _ ___ _ ___________ +_WORK_________ _________� <br /> C OTHER INFORMATION <br /> , <br /> O 1 1 PHONE # <br /> 1 PHONE # <br /> .. ....r.. ......... ..... .1'11 -1 <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY 1 DATE UST INSTALLED <br /> 1 39- <br /> 1 T 1 39- <br /> 1 A 1 39- A! i <br /> N 39- <br /> K 39- <br /> 39- 1�- <br /> 39- <br /> 1111111 I I.. .......i ..... .... ...... ,... ...... .. ...... ....... ...... <br /> L 'APPROVED' 'APPROVED WITH CONDITION(S) DISAPPROVEDI <br /> 1 A 1111 P1 f, �, 1p. SHE ATTACHMENT WITH CONDITIONS11111fI1 <br /> 1 N 1 PLAN REVIEWERS NAME N 1�fV1 DATE I(f <br /> ....... .... ... .... .... ......r. ..��. . ....,. ..... .,.... .... .... ..... .., ............. ............... i „ . ...... ,. .... i . i, <br /> .. . r..... .. ............. ............... i ... i. ......r. ..., i . ii11 <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 <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: n/� � TITLE U •DATE \A.0 U b <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 /> e l a <br /> Name �e� ,,"�p_�F �T dfess toSn� l� L� : S�^S n),')- Phone # <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />