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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3RD FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> —TANK RETROFIT _PIPING REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT <br /> +' -------------------------------------------------------------------------------------------------------------------------------} <br /> ' ' EPA SITE # , PROJECT CONTACT 4 TELEPHONE # <br /> +----------------, --------------------------------------------------------------'d ''`' - Am-------------------- <br /> F ; FACILITY NAME ' PHONE # <br /> ' C I ADDRESS -------------�-'_`_--- <br /> oI -------------------------- t2 !-- _e—------------------------------------------------------------------------- <br /> L ; CROSS STREET <br /> , <br /> ' I +--'------- ------ <br /> T f OWNER/OPERATOR PHONE # 1.� i <br /> Y ' a�- C rvti -gyp vl -� <br /> , r <br /> + -- --------- ------^----------- ---------- ------ -- <br /> - C 1 CONTRACTOR NAME- �y^ - .. - <br /> 0 + - -- (� ;y�� +_ �- � `��� - ------PHONE_# L�O13-( 03 S-- <br /> N ; CONTRACTOR ADDRESS 40 �r 3 uC __ te a-, 5� A 7S'j CA LIC #__ _ '_CLASS ¢�_,�.�j,t, ; <br /> --------------------`--4f - -----------_-- � ---------- ----- ° <br /> ± AR INSURER--�AI/ L" `Ii t��SLiLxL_._ „Sr-�---------------------------------+-WORK_C------�'' ��4.V���Q�•,{ �----' <br /> C ; OTHER INFORM�A�TIOONN 11S� <br /> 0 , PHONE # <br /> , <br /> PHONE # <br /> -------------------------------------------------- --` <br /> ; TANK IDS# TANK SIZE ; CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED <br /> 39- <br /> T i 39- <br /> i A 39- <br /> N I 39- <br /> K 39- i <br /> 39- <br /> 39- <br /> P ; <br /> L 1APPROVED APPROVED WITH CONDITION{SI DISAPPROVED <br /> A i 1 EE ATTACH T WITH CONDITIONSI <br /> N ; PLAN REVIEWERS NAME DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH S AQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. ER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> .. .. ;. THAT IN THE.PERFORMANCE OF THE.MORK FOR WHICH THIS PERMIT IS.ISSUED;- I.SHALL NOT EMPLOY ANY.PERSQN IN..SUCH.A.MANNER AS .TO.'. <br /> A' - .. <br /> BECOME SUBJECT TO WORKER�Ia NMPENSATION LAWS'.OP.CALIFORNI .'" ..CONTRACTOR'S�HIRINO.OR SUBCONTRACTING.SIGNATURE CERTIFIES- THE - - <br /> - FOL,LQWING: "I CERTIFY THAT.IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT -IS ISSUED, ISHALL EMPLOY PERSONS SUBSECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: �[j-� Q-d.l� �v' - 'GLL,[L�LJ TITLE &NAt) 4C4.l.CIL ATEF "" v <br /> -. <br /> ----------------------------------------------------------------------------------------------------------------------------------- <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name MAKI tib V. u�C- i"OX- Address_ 41rO 6-kiat4f SZ1, CA Phone # ;4b <br /> Signature7,ya,�- U- <br /> EH230038 <br /> (revised 1131102) <br />