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I, D,) 35� 0 SAN JOAQUIN COUNTY OCT 2 3 2003 ENVIRONMENTAL HEALTH DEPARTMENT 304EWESERAVE,3R0FLOOR NVIRONMEN f HEALTH STOCKTON,CA 95202 PERMIT/SERVICES 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: )CTANK RETROFIT_PIPING REPAIR/RETROFIT_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT -------------------------------------------�---w-----------------------------------------------+ EPA SITE # 1 PROJECT CONTACT 6 TELEPHONE #,� yA--- � ---- -�Q F FACILITY NAME ,`V A Mip M I PHONE # ----------------� ------------------------------------------------------------- i �j. nn I i + ADDRESS_ -� --� --- R--`-- ---------------- I i c L CROSS ST)> �� FI2__ S1 Stip T -------------------------- ---- -------- -------------I T I OWNER/OPERATOR ---- I PHONE # -Y------ _c,u �T--c�-aS ---Q� ��►�T - -�-�— ------------------- ' �_ -(_QI - - W— 3_qq------------ C C 1 CONTRACTOR NAME S`�s I PHONE # 0 +------------------------- cALLE� __��,YRpc. 5_ - ------------------------- �c�=aZV- --------i { N I CONTRACTOR ADDRESS a C ( S S { CA LIC # I CLASS I T +--------------------- ` ----��N�4-��-- -)-- "-4 S�v�A-------------------------------------- -�---- I R I INSURER_S'I --FUN """'-------------------------------- I WORK.COMP.#4(0)S O Q4�t 03 IA I-------- 5' -- - --------------- ---------------- ----- d---------- C 1 OTHER INFORMATION 1 1 0 1 1 PHONE # 1 IR +------------------------------------------------------------------------------------+----------------------------------------{ 1 1 PHONE-# { +- -i11 {i{{III{{I{III{IIII{I {II{ IIII------------------------------------------------------------ --------------------------------- ' i 1 TANK ID # 1 TANK SIZE 1 CHEMICALS STORED CURRENTLY/PREVIOUSLY 1 DATE UST INSTALLED 1 I { 39' { { I T I 39' { 1 A l 39- 1 { I I N l 39' K i 39- 39- 39 9-39- I �---lilllllll li{IIIIIIII{{ {ill {11{{Ilii{{{ 111{I�I11{1 .11lil{ 1111111111 111 'I Illilill{ II{1liiiiliiliili {liiliiliiillill {1111 IPI I L 1 APPR APPROVED WITH CONDITIDISAPPRO I A 1 I E TTACHMENT WITH CONDITIO S) 1 N I PLAN REVIEWERS NAME - DATE 1 + - illillilii{ {11iiIlillillill 111 ii {i Iil i 111ii 111111{ 111 { 111{{1{{{ 11{{ i Iii { { {1{ i lli1iHI M I I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF 1 1 SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 1 1 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 I 1 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE 1 1 FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO 1 1 WORKER'S COMPENSATION LAWS OF CALIFORNIA." { I { I 1 1 APPLICANT'S SIGNATURE: TITLE A�1`N� DATE---------------------------------------------------------------------------------------------------------------------------- I 1 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 DAh Aur r- FTS Address "d �.A, G 4 90OSA Phone # Signature �� EH230038j (revised 1/31/02) 1 .