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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3"0 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 +---------------------- ----------- -- -- - 1 { EPA SITE # { PROJECT CONTACT & TELEPHONE # {{ +---"------------------------------------------------------------------------------------- ------------------- { F FACILLTI NAME- PHONE # { C { ADDRESS -- DDDR DDDR - DDDR - -- -- -- ,JToci� Tom --DDDR-- DDDR- 1 L i CROSS STREET -- ------------------------------------------------------------i I = --DDDR-- --- --- -- --------------------------- 1 T I OWNER/OPERATOR _CC y� //� 1 1 - --- - -- - - - -"- { Y I � �Jl Y�-' ARD lDGtC�J LLC- I PHONE { t *----------'----r - DDDR-- - ----'�__-- +--------- 3 {-C { CONTRACTOR NAME I -- -� _"' 1 0 +-------------------- '1_7___ -�__�__----------- c!/G_S' bi_D--- PHONE # { I ----------------"---'---DDDR------------'DDDR- vL IN { CONTRACTOR ADDRESS 2'7G --- / /i_ _� , ♦G �yam---DDDR---I CA LIC C'/---I-CLASS�Id R"'✓ �j� T + - DDDR ------DRESS-y42 films /tea '` (� O { R { INSURER //�� /�/� C(/�� ...................... __`_____7 DDDR-{ A I---------� 2KIl�__-_� �-- /�C , I WORK.COMP.# ZdOO� ----- -----------------------------------+---------------9 - ----------lf��...3 { - C OTHER INFORMATION I T ----------------------- -------I 0 i ----------------------------------"-------------------- -----------------------------------------' { { PHONE # R +DDDR---DDDR- ----------------------- -------- --------+------'---DDDR--------------------------1 { PHONE # -------------------- 1 I III III I II III --------------------------------------------------------------------------{ TANK ID If { TANK SIZE { CHEMICALS STORED CURRENTLY/PREVIOUSLY { DATE UST INSTALLED I { 39- { { 'T 1 39- I I 1 I A I 39- { 1 { N { 39- I K 139- 3 9 9-39 { i I 139_ 11111111 II III III IIIIIIIII 111 1111111 IIII 11 III11 II 1 II I II I III I 1111 I 1 I ' 11 II 11111111 I II I + 111111111111111 { 111IIII111111IIIIIIIIIIIIIIIIItII 111111111111111 {11 { IIIIII II111{ { { {1 {{1111{IIIIIIIIII111 {11{ I11111111111111 ' PI 1 1 I Li _ APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED i { A { (SEE ATTAC-IM&NT WITH CONDITIONS) ' { N { PLAN REVIEWERS NAME i +---{il{iil {I{{II{II { {iI { iii{ {{(IIII {ii{1{I {I{ { { Iiliil{i{I{ { { i { {ii{{{III { { I {II{ Iii{iIi {I {i { { ID`TE II IIII{i{i{{ii{i {Iliii{{I { {i{ {i { I 1 1 { APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF I SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY { { 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 1 1 { i I I ' { APPLICANT'S SIGNATURE: TITLE DATE i { 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. NameAddress 7 6lJ( 14 ,U� Phone #?�91v�/ci 3335 Signature EH230038 (revised 1/31/02) 1 1