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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 FROMM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW. <br /> TANK RETROFIT -'PIPING REPAIR/RETROFIT_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> _ <br /> 1 i EPA_BITB i PROJECT CONTACT A TELEPHONE ► (1.b ,.�1 -_-i1 <br /> __ ___ <br /> ' F I FACILITY NAME �{' i PHONE i �Iq <br /> C I ADDRESS --.@ __-� �1LGb_ ' <br /> I L 1 CROSSSTRE----_-T <br /> I +_CROS__ ______,X..��tL�B__ __________________________________________________________________________________________1 <br /> T OWNER/OPERATOR i PHONE <br /> --------------------------------------------------------------------------------------------------------------------------------- <br /> I C CONTRACTOR NAME 1�:!_LLLCC..-. �u1.tY1_S_ S'l4.Yr>_`i-r---'lY1C-------------- PHONE ► 12�=�"l�M.-i__--------j <br /> 1 0 +------------------ -- - (� --- --� <br /> I N i CONTRACTOR ADDR855 I (/�\_ cLM_l'��/A______________ ___ CA LIC i__�d _j_C -_____C gs__6akj <br /> 1 T }______________________ <br /> ' R 1 INSURER I WORK.COMP.► )-237Z-1 U3 <br /> I C 1 OTHER INFORMATION <br /> I O I I PHONE i <br /> I <br /> I PHONE ► <br /> +---111111111111111 F111 R ���„�� ______________________________________________________________________________________________ <br /> i TANK ID ► 1 TANS SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY 1 DATE UST INSTALLED <br /> 39- <br /> 1 T 39- <br /> A 1 39- <br /> N 1 39- _ <br /> R 1 39- <br /> 1 39- <br /> 39- <br /> ......,1111 ,III„.,1111J11111 L'1L'L'1L'11111111111��� „����1L'1111111L11111111111„�„��„�„„ <br /> 1 P 1 <br /> 1 L 1 ”✓ P'rVED'r APPROVED WITH CONDITION(S) DISAPPROVED <br /> 1 A 1 , /I f””, )1' (SEE ATTACHMENT WITH CONDITIONS) <br /> N-i PLAN REVIEWERS NAMEht I DATE <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 PHRMIT 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 FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA.- / / / 1 <br /> APPLICANT'S SIGNATURE: /.! //A - Wl Cl- 1AWfY�/lt. l E. bc4r-. DATE �l alc�y <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 rsg ponsibility for the billing by signature and date below. <br /> eN Ce_SFn x� 4 .��Jkc ,tr7 <br /> Name Qbt ddress loll bu,nr, A�0 4�tla Phone #�1Uk_S7i-�49S� <br /> Signature 70 <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />