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SAN JOAQUIN COUNTY
<br />ENVIRONMENTAL HEALTH DEPARTMENT
<br />304 E WESER 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 />EPA SITE #
<br />F ; FACILITY SANE USA �Gp
<br />A1__________________________ `1
<br />CADDRESS
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<br />T : OWNER/OPERATOR
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<br />. .( C i CONTRACTOR NAME
<br />N I CONTRACTOR ADDRESS 'QO
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<br />i R INSURER Oak- �`
<br />1 C I OTHER INFORMATION
<br />IT +_______________________________
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<br />11TANK ID1M1t
<br />PROTECT CONTACT i TELEPHONE R
<br />1 PHONE #
<br />U&T31
<br />1 PHONE #
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<br />PHONE '#'r'
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<br />1 PHONE #
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<br />1 PHONE If
<br />__________________________________________________%___________;___________________
<br />TANK SIZE ; CHEMICALS STONED CURRENTLY PREVIOUSLY DATE UST INSTALLED
<br />1 L APPNVVW APPROVED WITH CONDITION(S) DISAPPROVED
<br />; A 1 ( ACHMENT WITX CONDITIONBI
<br />N i PLAN REVIEWERS NAME K//�/DATE
<br />. ..„ ..„.....,,,v.,, ,.,.
<br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COGHTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF
<br />SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY
<br />' THAT IN THE. PERFORMANCE OF THE .WORK FOR WHICH THIS PERMIT'IS ISSUED,i � I, SKALL NOT RMPLOY ANY; PERSON IN;,SUCH A.MANNER A$ .TO
<br />BECOME SUBJECT TO WORKER) COMPENSATION LAWS 60 .CALIFORNIA.” .CONYAACTOA' S � HIRING OR SUBCONTRACTPNG SIGNATURE CERTIFIES THE '
<br />. FOLLOWING: 'I CERTIFY THAT. IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 39 ISSUED, I -SHALL EMPLOY PERSONSSUBJECTTO
<br />WORXZR'S COMPENSATION LAWS O/F`CA-LIIFF.OR-N.IA.- W/I /A -' /c�-1/, /A�,� (� II �/y�
<br />APPLICANT'S SIGNATURE: L A(9�l(,W �• /V U TITLE` igii'I:La VTINADATE I140ImyM
<br />_________________________________________________________________________________________________________________________________t
<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 VAAfZ,TW V. WGC�Address 1 tb QtkAa- t)FS-I CA 9,'QQ_ Phone #,409 �3(3—fo03Q
<br />Signature I/u a_t� V - d'we��
<br />EH230038
<br />(revised 1/31/02)
<br />39-
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<br />39-
<br />1 A 1
<br />39-
<br />1 N 1
<br />39-
<br />1 X 1
<br />39-
<br />I 1
<br />P
<br />PROTECT CONTACT i TELEPHONE R
<br />1 PHONE #
<br />U&T31
<br />1 PHONE #
<br />', .. ..
<br />PHONE '#'r'
<br />X08 = a= :,
<br />--------------------------- - -
<br />`fg S L} _ cines'3 CInIJDoo14
<br />----------------------- 4_____ _-,
<br />1 Nowt. came. # L, 14 2 <'a—
<br />:
<br />1 PHONE #
<br />-----_
<br />1 PHONE If
<br />__________________________________________________%___________;___________________
<br />TANK SIZE ; CHEMICALS STONED CURRENTLY PREVIOUSLY DATE UST INSTALLED
<br />1 L APPNVVW APPROVED WITH CONDITION(S) DISAPPROVED
<br />; A 1 ( ACHMENT WITX CONDITIONBI
<br />N i PLAN REVIEWERS NAME K//�/DATE
<br />. ..„ ..„.....,,,v.,, ,.,.
<br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COGHTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF
<br />SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY
<br />' THAT IN THE. PERFORMANCE OF THE .WORK FOR WHICH THIS PERMIT'IS ISSUED,i � I, SKALL NOT RMPLOY ANY; PERSON IN;,SUCH A.MANNER A$ .TO
<br />BECOME SUBJECT TO WORKER) COMPENSATION LAWS 60 .CALIFORNIA.” .CONYAACTOA' S � HIRING OR SUBCONTRACTPNG SIGNATURE CERTIFIES THE '
<br />. FOLLOWING: 'I CERTIFY THAT. IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 39 ISSUED, I -SHALL EMPLOY PERSONSSUBJECTTO
<br />WORXZR'S COMPENSATION LAWS O/F`CA-LIIFF.OR-N.IA.- W/I /A -' /c�-1/, /A�,� (� II �/y�
<br />APPLICANT'S SIGNATURE: L A(9�l(,W �• /V U TITLE` igii'I:La VTINADATE I140ImyM
<br />_________________________________________________________________________________________________________________________________t
<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 VAAfZ,TW V. WGC�Address 1 tb QtkAa- t)FS-I CA 9,'QQ_ Phone #,409 �3(3—fo03Q
<br />Signature I/u a_t� V - d'we��
<br />EH230038
<br />(revised 1/31/02)
<br />
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