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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3R°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 REPAIR/RETROFIT i___- _________________________________i ___- . EPA SITS « PROTECT CONTACT 6 TELEPHONE 0 _Tr/h C/ wE (9/6) J __ ___ _____ _ _-. _ ___ F 1 I FACILITY NAMESt # p PHONE ► -- -CO CO GS 8 C I ADDRESS I4-------------- 1,✓. fl -----L__r_-_v_E--------------_--------------------------------------------------------- { I I L I CROSS STREET -- k - /OP1 /----- -------------------- ---------------------------------------------------------------------------I { T I OWNER/OPERATOR I PHONE k { Y I Ot�urs BnC I YJ,5 ya7 9653 1 I - 4------------------------ ----------------- --+---------------------------------------- 1 C I CONTRACTOR NAME wgY'"E_----�E1PR�! /N c I PHONE y C 9/G)_(,y(, 9680 I ID 4------------------------ --- ------------------------------�- ------iiiz-------I I N I CONTRACTOR ADDRESS j0 r�79/N KINE------------------1 CA LIC w 3003115 �S09,C�IC,o 6066 IT 4----------------------------- ---------------------- I R I INSURER t3m,�RICgN__ /_j t--- 1953ufigA ccr -----------------------I wOEK.CONP.M WC 31A lI Y7-------I IA I__________________ _____ C 1 OTHER INFORMATION I ______________i IT 4___________________________________________________________________________________i__________________________ I D I PHONE 0 _____________________________4________________________________________1 R 4_______________________________________________________ 1 PHONE 0 1111{IIIIIIII{IIIIIIIIII{IIIIIII______________________________________________________________________________________________ TANK ID # { TANK SIZE I CHEMICALS STORID CURRENTLY/PREVIOUSLY I DATE VST INSTALLED I { 39- { T T139- I � A { 39- { { I N 1 39- IK39- 13 39- 1 4---IIIIIII{1{I{I I I IIIIIIII {lill{{{IIII111 IIIIII VIII II 1111111 Illllllli {{I III II II { Illillill I11111111{� IF I I L I APPROVED APPROVED WITH CONDITION(S) DISAPPROVED I I A I SEE ATTACHMENT WITH CONDITIONS) I^�N Oli7 I N I PLAN REVIEWERS NAME ) Nf DAIS 4---IIIIIIIIIIIIIIII{III{III { Ililllll{iliilllillT iiillllllllii Illllllil {IIIIII{Ii { Ii {{Illi I { {II I I{{III gill{Till I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN OWNER OR COUNTY ORDINANCES, STATE LAWS, AND RULES AND WING: 'I C OF { 1 SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. 04RTER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY l 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 l I BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE { 1 FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR MICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I 1 WORKER'S COMPENSATION LAWS OF CALIFORNIA.- i I I APPLICANT'S SIGNATURE: �/ TITLE /r-)PGT MGA DATE 4______________________________V _______________________________________________________________________________________________4 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 Zlm 5111ti,• A ss 36' Ag,x �5Y S 5Oc 6-L?ho n e# 9�G 8`/96 yas Signature u EH230038 (revised 1/31/02)