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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3RD 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 ELOW:____TANK RETROFIT YPIPt"REPAIR/RETROFIT ___UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT +------------------------------------------------------------------------------------�--/-(------`- /-�------ ----------------------- 1I EPA SITE # I PROJECT CONTACT & TELEPHONE #1! �^� _ ►V!�////A / +----------------- --_k _-`�= 1 --------- a_ __- F FACILITY NAMEy I PHONE #/ G --- A _________________ _ > C!__�__ ------091 1 -DDDR-- --DDDR- _ I ------------------------DDDR-- DDDR - - { C I ADDRESS L.E� i-��L?% n-- -- -� I +---DRESS------ - --- (-�J L/ L I CROSS STREET Vks ---------------------------- T I OWNER/OPERATOR -- -----------I PHONE # 1---+ - - - - - - --- I C I CONTRACTOR NAME PHONE # IO +DDDR -- - - -- - ----------------------------- , - '----R----------------- I N I CONTRACTOR ADDRESS 1 CA LIC # I CLASS IT +------------------------------------------------------------------------------------------- - --------------------------'----- I R I INSURER i A i-------R I WORK.COMP.# ---------------------------------------- 1 C I OTHER INFORMATION T +____________________________________________________________-_ -----------------------+-----------------------------------DDDR-I 1 0 1 1 PHONE # R +______________________________ ------------------------------------------------------+--------------------DDDR-DDDR-DDDR-DDDR-i PHONE # I +_-_Illlillllllllllllllllillllllllil_______________________________________________________________________ 19TANK ID # I TANK SIZE 1 CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 3 - I t Z04 0 1 T 1 39 --� i .Q`)Q cy I I I A 1 N I 39 1 K I 39- 39- 39- --1111 9_39-39-+---1111 Ill iiiiiiilllilillllliiliiillIII 11lil'llIll ii'iillliiliiillliiiilillliiilililllllllilIHi ill HI1: 1111IIIIIi1111111IllI P I I L i _APPROVID _APPROVED WITH CONDITION(SX _DISAPPROVED 1 A I (SEE ATTA TH CO O N I PLAN REVIEWERS NAMEVeV--1%L'l\V, p 1 DATE ; +---IIIIlI1111111111111111111111Illlllllllllllll111111111 1111 11111 I II III 1 11 111111111111111 111 11111111111111111111 I 1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, LAWS, AND RULES AND REGULATIONS OF I SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY I I 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 I 1 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I I WORKER'S COMPENSATION LAWS OF CALIFORNIA." I I 1 I 1 I I 1 APPLICANT'S SIGNATURE: TITLE rfl'j(�/ Y LJL /,4�` DATE v/ }------------- ----------------------------- BILLING INFORMATION: �c - � A-cf � 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----------------- Address -----------Phone # 1