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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3R 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 V PIPING REPAIRIRETROFIT __UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT ____________________________________________________________________________________ _______________/______l___________y_w.I EPA SITE # I PROJECT CONTACT 4 TELEPHONE # VAI tI , G CIILsC \Z�9/ IY94 14 I -------------------------------------------------------------------------- ---. F I FACILITY NAME V PPS- t oo � 204 PHONE #( ) n( yt-q y IL I A,______ ___________________________________o__________ ____________________________________________________I C I ADDRESS 3r,�o S. Vk S�+clr•E'e C,�_ 4 Szob I 11 t------------------------------------ �'----- +-------------------------- I L I cRDSE sTREEr �------ - --------------- r - - --------------------------------------- I I I OWNER/OPERATOR I PHONE # I Y I Vw( p�tC�L �4"' c_. g-ceol), Z,.e 1 z`*) �f Yg• Sq/L I I---t--------------�----- - - (��1 1--f-----------------t-------- -------------------------------I 1 c 1 canaAcroRemme T-6301., N4901eu CIDw W%r _croa. I PEONE # 0 . 104------------------------------------------------------------------ ---------------�3---8�8-G43-- P" ---sem N I CONfRACfOR ADDRE93 P.0 . &_V 7 1 (.q A6,rn CA V114 CA LIC # (o92,2 3 ff I cx s 4-Go wc. I I 1 T _______________________________________________________________________________________ IRI INSURER Sjro'I,— I woRx.caae.a I IA I-----------------------------------------------------------------------------------*----------------------------------------I I C I OTHER INEORWfTION T -------------------------------------------------------------------------------------________________-________________________I 1 0 1 1 PNONE # I IR---------------------------------------------------------------------------------------------------------------------------I I I I PHDNE # I +---11111111111111111111111111111111---------------------------------------------------------------------------------------------- I I TANK ID # ITANK SIZE I cBEmlCALS STORED CORRENTLY/PREVIQISLY I MM UST INSTALLED 1 1 39- 1 1 1 IT139 IA139- I I IN139- I I I I IK139- I I I I I 1 39- 1 1 39- I P I 9-1P1 / I L I APPROVED ✓APFROVEO WITH CONOITION(S) DxSAPPROV® I A I �/ �� (S ATTACHMENT NIM CONDITIONS) [' I I N I PLAN REVIEWERS NAME vVY1 A i��{y� 4 DATE 'CJ +-'-IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIItllllllllllllllllltlllllllllllllltlllllllllllllllilllllllllltlllllll I I APPLICANT MUSS PERFORM ALL FORK IN ACCORDANCE WITK SAN JOA(A1IN COUNTY ORDINANCES, STATE IANS, AND SOLES AND R£LOLATIONS OF I I SAN JOAQMIN OIUNW, ENVIRONMEN'PAL HEALTH DEPARTMENT. ONMER OR LICENSED AGENT'S SICmmT CERTIFIES THE ML ING: 'I CERTIFY I I THAT IN THE PERFORMANCE OF THE WORK POR WHICH THIS PERMIT IS ISSUED, I SHALL NOT &M ANY PERSON IN SUCH A MANNER AS 1O I I BECOME SOBJECI TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I I FOILOWZNO: °I CERTIFY THAT IN THE PERFOMWNCE OF THE FORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL ENPMY PERSONS SUBJECP 10, 1 1 FOEKER'S COMPENSATION LAWS OF CALIFORNIA." I I I I I �.(J^- 1 3 I APPL=CANL'S SIGNATURE: TITLE 0C0I0 C[. w DATE t•��q�� I 1 J I y_ ______________________________________________________________________________________________________________________ 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-----_ ---__--_---Address—_--- — ----------------Phone#------ 1