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11/30/2004 11:53 2094683433 FIFTH FLOOR PAGE 04 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3"6 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 REPAIRIRETROFIT <br /> +---_...---- - -------------- _ <br /> ( ( EPA SITE # 2 I PROJECT CONTACT 6 TELEPHONE # -- _�__ -------- <br /> EPA <br /> S ---i <br /> I +------------- --- -- 3�--------------.--- -------- L2 0_ -- - <br /> I F ( FACILITY NdIMarmJ�n.Rni j ��y ' PHONE it `---- --i <br /> C �-ADDRESS,-.I Coo__U`_�LYSr��tJ-- --�` '- ------^----�--- -------------------------- ei. ------------------- <br /> 1 <br /> -------•---------i <br /> 1 +- ' <br /> I L I CROSS STREET <br /> II +------------------------------------- -------------------- <br /> T I OWNER/OPERATOR 'n.[�^�_ Y^ ------------------------.-- (-------------....-----------------------i <br /> ( Y 1 U V A l co PHONE # - <br /> !-0 ------------------ ? _ -----------------------------------------+--------- <br /> f o �� � -- -p[`--------- I PEIONs # QCO_ <br /> N I CONTRACTOR ADDRESS UQ 1 I CA LIC # 3LI CLASS�� -10., <br /> I T *--------------_... _INSURERp �/_�ffnakn-- +-`--__�C�. �.. i?�.------------------..i....---------------...Z?-L�----- - <br /> RA i ------- 5-1��_.�Qm�___illS__� i_ _ + WORK_COMP_# o�fit -00OOZO 1 <br /> ---------- -L <br /> C I OTHER INFORMATION I I <br /> IT r---------- ----------------- ------------------ <br /> Io I - I PHorrE # ------------ <br /> ------------------------- <br /> _. <br /> --- -------- -------------------------------- -------------------------------*----------------------------------------i <br /> R ---- ' <br /> ' - I PHONE $ <br /> +---11111111111111IIIII11111i1111111•---•-----------------------------------------------------------------------------------------I <br /> I ( TANK ID # ( TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY ( DATE UST INSTALLto <br /> 1 39- I I I <br /> I T ( 39- f <br /> i <br /> INI39- I I <br /> 1139- I I I <br /> ! 139- I I I I <br /> 1 1 39- 1 I I I <br /> + --11(11 I IIIIIIIIIIIIIIIIII rinI 11:11 ;Ii i 111111 1 m I;i I I I I I I I I I I I I I I 111 1,1111111114,11111 i I i I I I I I IIEIIII <br /> P i <br /> L I APPROVED APPROVED WITH CONDITION($) DIS"FROVED ' <br /> I A ATTACHMENT WITH CONDITIONS) <br /> I N I PLAN REVIEWERS NA DATE <br /> ---IIIIIIIIII111111111111111111I Ill(I M 111 111111H IIIIII1111:T1ITf1T 111 ITTI,1 �� lill'ilifflili 111111111111111111111HI <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS. AND RULES AND RECO ATIONS OF <br /> SAN JOAQU-IN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING= -I CERTIFY <br /> THAT IN TH8 •PERFORMINCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO ' <br /> 1 RECOM3 SUBJECT TO WORKER'S COMPENSATION LAWS OF =XrORNIA_- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE i <br /> ( <br /> FOLLOWING; -I CERTIFY THAT IN THS. ZtRFORAANCE Of TEES WORX FOR WHICH THIS PERMIT I5 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORICER'S COMPENSATION LAWS OF CALIFORNIA <br /> I n <br /> APPLICANT'S SIGTNATA8z � j�— TITLE I,0 &Cd– <br /> +-------------------•---....-------------------------------------------------------------------------------------------- -------I <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 /> SC4IC"'c`^ rlo <br /> Name_00-1v-c Address 3c) 4""' ,R�z. 5�� � cc-�`- , Phone#6 Q 6q , c?&30 <br /> Signature <br /> -m"L— <br /> EH230036 <br /> (revised 1131102) <br /> 1 - - <br />