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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,30D 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. L _TANK RETROFIT_PIPING REPAIR/RETROFIT_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT -Y_ "M11.I6/4mfazko- 1 1 EPA SITE p 1 PROJECT CONTACT i TELEPHONE p M�-W�*U�AA 14oF-a13-1 03 V ____ ____ _______ __________ i F PACILITY NAME i PHONE p Sa. �d4—�(n l -CSSC' _________________________________________ i C I ADDRESS 1 a' 0- - - uu��'� c4�b---'dile�`------------- L I CROSS STREET Dtjo VLb - - - - I -HONE --- - - -- - 1 T T I OWNER/OPERATOR S 1 I �M I ' r PHONE p - r a�dva �TCLLJ Kam I aeq- k6l -SSS'S"' i C 1 CONTRACTOR NAME Sn"i'cf� &41KLjj�-Q_U'�.5------------------------------PHONE p 46_k-ala-603 3----- D +------------------- - - -- (�U----- A,.^ 1 N I CONTRACTOR ADDRESS '"9", ' '4sf ,��,,JJ '�2 �/.l 7T.TQ-W'7 j� I T -------------------------------_____________________________________---_L c_-______ __ ___1_______CLASS-_ W rD4 l✓IU}Ta __-_'T'�1----------------- 1 ___ __ ___ 1 1 A. i INSURER StE � � w er WORK.COMP.p q`3 74t(D - w r "V14 Ai__________ ______________________________________________________+________________________________________r 1 C 1 OTHER INFORMATION i O , i PHONE p iR +____________________________________________________________________________________ I PHONE p ____________________________________________________________________________________________ ' i TANK SIZE 1 CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED ' ' TANK ID p -_ 1 39- I T 1 39- 1 A 39- 1 N 39- 1 K 39- 1 39- 1 39- }___111, rrrrr,,,,, ,r, r„rr, ,11111111„ r,'1' 11111111,111/11111 L'111 L', „ 1 L'11111111,r, r„r 1 P I L 1 APPROVED ✓ APPROVED WITH CONDITION(S)DISAPPROVED I A i (SEE ATTACHMENT WITH CONDITIONS) I N 1 PLAN REVIEWERS NAME ( T44ffi5 - DATE riii .i . ...... 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 POLLOWINO: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LANE OF CALIFORNIA.- APPLICANT'S SIGNATURE: ('(.�(�LtU VTITLE —eu tfruYl—_ 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. 9Vla. Name HAizTkW '4, W611U#4 A#-) Address 4yb doia t ku,, Sg IncPhone # 46V-,)435403V Signature 7u'_tcu, EH230038 (revised 1/31/02) 1