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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 REPAIRIRETROFIT_UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT <br /> • EPA SITE # PRQTHCT CONTACT 6 TELEPHONE ({ ' <br /> 1 F 1 FACILITY NAME _ _ _ _C1_u_ IV �,__��1__-OC -FQN�_� N "�EJ13______ _________________ <br /> 1 A +_________________ <br /> �P_T€w� g- -- - - - --------------'5--------- <br /> Z o8 --- upt� 6-- --o <br /> { C ADDRESS R / ,�_ <br /> L -CHOSE---- STREET ---u�-p�R <br /> T ; OWNER/OPERATOR '-� PHONE # <br /> Y 1 �'p.�'Ewa ____J_+o¢ES_J.Nc_ ------------------- ZOti -4101-5555 <br /> ---+------------------- + - - ------- <br /> I C ; CONTRACTOR NAME F17INE ' S�__ C' t9_N__�LL�--------------------- PHONE a 916_(oZ4-14_Q_.__---------; <br /> Q- - � <br /> N I CONTRACTOR ADDRESS L 4 __ 1l --------- 1S A NAZ_ <br /> C _ J^ ..-', G LIC p - CLASS <br /> IT -------------------------------- P_-IJ�€__/_-- _ -JCC __---------------------------------------J. _ _ -I _ <br /> A cAN �►�{ I _______ I WORA.COMP.# WCOS9- __ _ <br /> __ 11 : <br /> �OL�� <br /> R INSURER Z_ S________1 <br /> I C OTHER INFORMATION <br /> ____ ________ ______________1 <br /> 1 O 1 ; PHONE # <br /> : <br /> 1 <br /> 1 PHONE # <br /> _________ _ ________ <br /> TAT 1111=' <br /> D # I TANK SIZE CHEMICALS STURM CURRENTLY/PREVIOUSLY DATE U T INSTALLED <br /> 1 39- Zonoo lnAS::9"L EA1� 0 <br /> 1 T ; 39- IV DOO G.PS- i�i.EM <br /> 1 A 1 39- IADQO 6.A�US ;�; <br /> N 1 39- <br /> X 39- <br /> 39- <br /> 39- <br /> ::: :................... .:: :: ::::,::::„::: ilii ::::: .....: ::::: ::: i ::::: ::: „::,::,:::: i ... .... ... ...: ii ::: i: i ::: <br /> P <br /> I L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATH <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY 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 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK POR WHICH THIS PERMIT IS ISSUED, I SMALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF <br /> CALIFORNIA." �/J <br /> I APPLICANT'S SIGNATURE: �y'' L LCnCIIC/ (!1i� TITLE VZ� �LbI� Z/OI DATE 6� <br /> BILLING INFORMATION: <br /> 5bE PDaU-�eNAI �'0)2.� -A-�Ac�tfn. <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 Address Phone # <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> i <br />