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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3R0 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 ZPIPING REPAIR/RETROFIT - UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT y________________________________________________________________ _________________________________ _________________- EPA SITE i I PROJECT CONTACT - TELEPHONE i ,{ —15 rt /' -r_ „q+ii'C I F ; FACILITY-------- NAME C�,/� *jL2t19_ , PHONE i It C�1L `� / I A ----------____•�___„_` i ____________ __________________________________-__-________________________1 I C ADDRESS Q =_II__1V3JI-,lltr __1.li.L�P1_ 1 3 _____ _ ___________________________________________________________________________I i L i CROSS STREET A'1 P_ , /1.,-.,� ./lr ______________________________________________________ ' I y__________________ Pd1-L`^_ ______I_________________________1 '.T 1 OWNER/OPERATOR - - PHONE i --------------------- CYC------'h --------------------------------------------- ------------------------------� y i C CONTRACTDR NAME ,( PHONE i 4•`-'6 / - - � �_ �_LT_ - �S- t - -------------- -- - - - - �- �5-----------i I N CONTRACTOR ADDRESS (C'��,�` //��,, .,�� 1 CA LIC ip(� c�1 r CLASS -w [� I T --------------------___ 4v 1+LZ`!�_lY1�11r=_______________________________JD lA_L_______�________ _____4- ---_______I 1 R ; INSURER I WORK.COMP.i 1 A ;--------- -551'�f;---fO-D---------------------------------------------+-------------I.7--74�GC------------ 1 C ; OTHER INFORMATION , 0 1 I PHONE i R i , PHONE i ________________ __________________________________________________________________________ TANK ID i TANK SIZE I CHEMICALS STORED CVRAENTLY/PAEV Y DATE UST INSTALLED 39- I T I 39- 1 A 1 39- 1 N 1 39 K 39- 39- 39- +___ r:r!,r1r X11 r:,., „r„: : . . ...r. P I L I T N PLAN REVIEWERS N J DATE APPROVED WITH CONDITION(S) DISAPPROVED 1 A J µNE AHI�gN'P WITH CONDITIONS) 11 W�Qr APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY 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 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' / I APPLICANT'S SIGNATURE: e/�(_`/[ TITLE DATE 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 Q11-c WA Address 1��C�, , r (�. a. Ssnz Phone # ,& � Signature In i ! EH230038 (revised 1/31/02) 1