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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,10 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 _.@'REPAIRIRETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT ________________________________________ ______________-_____-____________ -_--_----_-_____-_______-\-M-__ + I EPA SITE a PROJECT NNTACP R TELEPNOIS » t�4t:k.G C f fCtrON^ T_�q/ `f3^fr793 ETA --- — - ------- ------- - -EIRP---- ( (� /� (�IF 1 FACILITY NAME V4I\T,_-(�Eyf t +.O IC c.w eG_v011� K+cp,7y..J0+1\I PHOIID » CZ�Ci--�'F3 _Y713------i I I A®REEE 3-'N------------=--------1�--'�`---'-- ----`t_5---_-5-- ----------------------------------------------1 ew I = +IEEE---IEEE-IEEE-- - -- - tet- � - I I L I CROSS STREET II +__________________________________________ -_-_--_______________-__-__-______ -----__--_______________I I T I O /OPERATOR (1 �j,�� I FMNNS # Y I GM6 �aC irk}c_�"r`Dk4I. - -------------------..__.- -----__I ; C CO-------- NAmN--- R Y V : L WCjo' 'sjr I_L�o/. 1 I PH@]E # I 10 1 N I CCNTRACNR ADU SE65 ( At at 1Aue\ (��Y4Y1v.li��l CR LIC# I CIASS I IT +-___________________________________________ _-_---_-_____________ -_--__-_-_____I _. I R I IN9U I woiuc. .# I IA I___________________________ _-_-__-_-_________ -_---_-_-__+____-_____-____-_ I I C I OTmmii INFORMATION - I I IT +______________________________________________________ _-___-_-___+-_____________________-______________-__I 1 0 1 1 PHONE # I IR --------------------------- --------------------------------------------+--------------------------------------I I PHONE # I +---11111111111111111111111111111111----------------------------------------- I 1 ,TALAR IO# I TANK SIZE I O10NICAL3 STOR®CURRENTLY/PREVIOUSLY I DATE UST INSTALL® I 39- I 'itov0 1 P...dt n.cct( 1 T 1 39- Z Q o00 1 1 IA139- 1 11 ; N ; 39- I 1 11 IK139- 1 1 I 1 39- 1 1 39- I +---IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIitllllllllltllllltlllllllllllllltlllllltlllllllllltlllllllllllllllllll IPI L I _APPROVED APMR WITH CONNITTCNIS) _DISAPPROP® A I (SES ATTACHMENT WITH CONDITIONS) N PIAN NSVISNERS NAMB DATE I •---IIIIIIIIIIIL'IIIIIIIIIIIIIIIII;ILII;IIIIIIIIIIIIIIIIIIIIIIIII1111111111111111111111111IIIIIIIIIIIIIIIIIIIIIIIillllltlllllllllll ; APPLICANT MIST PERFORM ALL PORK IN ACCORDANCE WITH SAN JOAOIIIN COUNTY ORDINANCES, STATE ]AWE, AND RULES AND REGDI,ATIWS OF ; PSAN JOAQUIN COUNTY, FNVIRONNHNTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE POLILWING, •I CERTIFY 1 THAT IN THE ERFORMANCE OF THE WORK POR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPIYIY ANY PERSON IN SUCH A MANNER AS TO ; 1 BECOME SUBJECT TO NORI®t'S COMPENSATION LAWS OF CALIFORNIA." CNTRACIOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE 1 FOLLOWING: "I CERTIFY TEAT IN THE PFAFORNANCT OF 'ISE NWIiC FOR WHICH THIS PEWIIT IS ISSUED, I SHALL FS@fAY PERSONS TO I MIFUMIS CNSENSATION LAWS OF CALIFORNIA.° I I -.0L/�� /y [��"� y I 1 APPLICANT'S SIGNATURE; TITLE V'-'✓ ' A '�I� MW • lOLl 1 I1�ow 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 VA E-44L Wrok— Address 16� F�,N� C'-� Cafe Phone#_000 9Ye-nt _''Cfct"� Caa- ry 7 1