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a c SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3"O 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 REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT I PROJECT CONTACT & TELEPHONE Ji EPA SITE p (� I ---------------------------------------------------------------------------- F FACILITY NAME �,$ T 0.V 4 /� Q.Z- a� I PHONE # Z Oq a q A *----------------TQ----------- -------------- ---------------------------------------- -- ------9_ C I ADDRESS-------------------------------------------------- -------- -' 5 !-- G -- o S lf�---/eT- o--------- 0. C I - - --T_ -r-- -------- ---3_s =33_(x----------------' I L i CROSS STREET +___________ I _________________________________________________________________________________________________________________ T I OWNER/OPERATOR ' ; i I PHONE Y Q_,U_ooT Bros, (xo4) 9.6z-9 sG I---*---------------- ---------------------------------------------*- - - -------I I C 1 CONTRACTOR NAME "rC PHONE p O I0 +------------------------ -T-------- --.---------------------------------------------------�--y�-'!<�a l_-_�n_,1� °J N I CONTRACTOR ADDRESS �/ GV Q ,m . , D ri CA LIC `0 D J_ I CLASS ; T * 5°� S --------------- ------- f ....... ----- L}� I3;,C-f2fHh ; R I INSURERSTfTF_v_NA - ------____-� WORK_COMP_$ A ;--------------------------------- C I OTHER INFORMATION ; ' T _-----------------------------------------------__ i O.i I PHONE M R ______________________________________________________________________________________________________________________________I 1" 'III"III"II' "I"II"'Illtt_____________________________________________________--PHONE_-________________________________ TANK ID 4 I TANK SIZE I CHEMICALS STORM CURRENTLY/PREVIOUSLY I DATE UST INSTALLED I 139-T 39- I A 39- i ! N 39- K 139- I I I i 39- i i 39- +-- IIIIIIIIIIIIIIII IIIII IIIIIIilllllllllllllllIIltililttiil lliiliitiiiiii I I It it iiI II II I Ilii till) I litl til P L APV ✓ I ED APPROVED WITH CONDITION(S) DISAPPROVED ; A I (SEE ATTACHMENT WITH CONDITIONS) ; N I PLAN REVIEWERS NAME vy DATE o�S t7 +"-iliiiliilliiillllilllt�iiililii iii i " i iillllllllllilllll ililllilllll it Ilillilliliiiii� li it II III Illillilil I APPLICANT NUPERFORM ALL WORK IN ACCORD IITH SAN OWNER OR COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF I SAN JOAQUIN CO COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICINSID AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 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 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE ; FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I WORKER'S COMPENSATION LAWS OF CALIFORNIA." ; i I I I APPLICANT'S SIGNATORE: TITLE DATE I +_________________________________________________________________________________________________________________________,SSSS___* 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-o e�; Tra-y�l /0 7-w Address 15-4 o c 5. fFo-v-le Iti r2 oQ Phone#(�-6Y)4 8'2- 94s(, Signature /41 7W ieoI-4c4gr?Icp EH230038 (revised 1/31/02) 1