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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3AO 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 REPAIRIRETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT --____________________ _______________ ______________________ _______________________________________________________________ 1 EPA SITE # 1 PROJECT CONTACT 6 TELEPHONE # 1 F i FACILITY NAME 1 PHONE # d y � I __ __ _____________ IA ------------ cC ---�--`---------------`----------------------------------- a-------9�{8-a`7-3---I 1 C 1 ADDRESS µ� J J 5 /'ht� z (� i4 __________________________ _______I------------------------------------------------------_______-___________1 I LI CROSS STREET �_p - 1 I ______________________ 0 ---_________________-__-______________________________________________-_-_--______._ 1 T I OWNER/OPERATOR I PHONE # i - p_w sT --o�T__Pieo-ouc s-----------=------------��a s�fa� i I C I CONTRACTOR NAME -M-/ Te7u V I PHONE # 1 0 a___________________________�_+�__2______________________________________________________________ ___________________________ 1 N I CONTRACTOR ADDRESS •3ZU J-I—U V IA 6 b" ! CA LIC #_ GC _Q�it__---------------------------7- it SSS 1 _______ _ _ ______________________I T �___________________________ I R I INSURER 17—:F:: I WORK.COMP.# P Q od_ �+ Q t3,pta K_K_�_-SGS-xr�----------------------------------- ---- �?° �—' I C I OTHER INFORMATION I I Ta__________________________________________________________________________________________________I___________________________I 10 I PHONE # Gy ll0 - R _____________________________________________________________________________________ _____-__-_1_____4G]f ___!'Y_-______i I 1 i PHONE # 1 lilillililllllliillillllli11i1ii______________________________________________________________________________________________1 I TANK ID # I TASK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY i DATE UST INSTALLEDi I 1 39- / 000 rRSouNE I T I 39- i1 / rjQcgI I 1 l A l 39- .d h(9 _; e S J L4 1N139- I I 1 K 139- I 1 I 139; I ..111 1;;111 11111 I11111� 1.111 1 1111J1 111{ 11111111111111111 1111111 11111111� 11� 11111 1111111 II�f111.1111T(I P1 1 L APPROVED APPROVED WITH CONDITION(5) DISAPPROVED 1 A 1 lilllillllilllllilllll iiT ) 114(Sf,/TTACHM N PLAN REVIEWERS NAME rEVT WITH DATE i .. iii Tl� iT ilTiillllilili�T�l? illi 11ii111111ii ii I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOApUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF i 1 SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY 1 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 I 1 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I 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 I I ��a ,c ��„ I-,? o3 1 APPLICANT'S SIGNATURE: TITLE Lam/ __ _.� DATEi 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 �N� Address 3U-S L-!- yarL5�Pho et# SfbFs-/�9 � LVN Signature EH230038 I Con e Digo Aboute a+(7_0q) `109- 3L{0 t Glo an iwtspech'ov� (revised 1/31/02) M P' A-tw lint' Wino a�iGrio S' 2• At1ow C� SVS hrAY hohGe -fDr W aVpDi'(\+MtA4S !lre�,rl� aVW (kPn 1 3D ,2003