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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3RO 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 XPIPING REPAIRIRETROFIT-_UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT +------------------- -PCS a-------------- I I EPA SITE # i PROJECT CONTACT & TELEPHONE #f..JA\N'!F A,-jb<.-2Sc°�J � �_q6j 173`?1 { - -------- F I FACILITY NAME LA`{' �/-CI C 4F v k-v+/" I PHONE # Z-9 q8 7 A +----------------"---------------9-------------------�-------------------------------------------- ---- -------------------------i C I ADDRESS r q U__F_ L-A-T`i+2U T I/-0 --------------------------------'_------------------------------------------..___ LI CROSS STREET I ------------- ___--- ------------------------------I I T I OWNER/OPERATOR I PHONE # I IIy -------------------------------------------------------I I C I CONTRACTOR NAME Lr C q F-ZV 4 C-E-S PHONE-#--_-' I 1 0 +---------------------------------------------------- --------------------------------------pa ---------------------------I N I CONTRACTOR ADDRESS --S'--)-7 N ,2 KV IE L.J I CA LIC # '7©� 1 I Z I CLASS I RI INSURER-------------------------- - ------------------------------------------i WORK.COMP.#----------------------------r IA I------------------------------------------------------------------------------------+----------------------------------------1 C I OTHER INFORMATION I ___' IT +-----------------------------------------------.------------------------------ --+--------- { 0 1 -1 PHONE # -- S -q qu-1-730 I IR +--------------------------------------------------------------------------------- +---------- ----- ------I 1. I I PHONE-# i �-- �IIII{ IIIIIIIIIiI {f111�------------------------------------------------------------ --------------------------------- TANK IDI#II TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY 1 DATE UST INSTALLED I { 39- I 1 I i { { T I 39' A 139- 1 1 N I 39- I I { 1 I K 139- 39- 39— +---1 11111111111 9-39-+---1111111111111 II111 { II11141111111111IIII11111IIII fI1IIIfi1IIII IIIIIIIiiiiI11 { IIIIIIIIIIII11IIIIII�IIIIIIIIIIiIIIIIiIIIIII I L I APPROVED APPROVED WITH CO ITIO (S) DISAPPROVED I A 1 (S TTACHMENT CONb IONS) N I PLAN REVIEWERS NAME DATE C/ +---{ {1.{IIIIIIIIIfI { III { II { Iliu{ ilii{c Iiiiiii-�"iiil { 11 { ii ilil { { Ii �i{ iii { i { { { II IiI { ill �iili{I '{ Iiil{ ii {iii{ ii{iillill I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF { SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEP?..RTMENT. OWNER OR LICENSED 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 ' r 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 WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I WORKER'S COMPENSATION LAWS OF CALIFORNIA." ' 1 I DATE 1 APPLICANT'S SIGNATURE: C`-' i I 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 Le S4zozykcES Address S2--7 I'J- PA Vf"C Phone Signature C-Z�lj EH230038 (revised 1131102)