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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT • 304 E WEBER AVE,3RO 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: kk-MOY(T _TANK RETROFIT _ _ PIPING REPAIRIRETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT � _•--_______ TELEPHONE I EPA SITE N ---------PROJECT CONTACT-6-----------I t_ ---- 1-'R,�ti.o�� Cq 14\e�Q=� %0I I F I FACILITY NAME RRLIC_gY�O________ I PHONE I •--- f A ----------------------------- � a9_K_c.S SSS -I s 1 y� __________________________________________________ I C I ADDRESS 1-4 50 W t 1-50 A6 W R I II --------------------------------------------------- __ L I CROSS STREET K A PLO IIPJCh_ ________________________________________________I II ___________________ ___-__________.-•____ T I OWNER/OPERATOR _________________________________I I PHONE I Y I �p WEST_�oaT p aOpuc'r _, �� L--------------- 0-`1 - 333 ____ I C I CONTRACTOR NAME 'TA-1pT. . Z•^ti�" I PHONE 0 q $C"Q 1 O p O T N I CONTRACTOR ADDRESS 2 O u N D I CA LIC M (t I CW SS CI 14 T '� 1- y ----------------------------$ $ ------------ � I R I INSURERBa Kl K_K _ u XO :A Oct?- -- p�aC-�YL-ZI A I--------- K -------------- -----------------= ------- - - -• — . _ _ -_ -C I OTHER INFORMATION T -------------------------------____________ R 1 ----------- PHONE I R _________________________________________________________ ____________-_________ I I PHONE R IIIIIIIIII111 f IIIIIIIIIIIIIIIII______________________________________________________________________________________________ SANKII 139- I i t TANK SIZE i CHEMICALS STORED CURREL LY PREVIOUSLY I DATE UST INSTALLED I T 139- IL I I A 39- Z I I 1-1 K 39- Zac2 I i I 391 _ I 139. IIIII I I I IIIII I I I II I I . I II I I I I I I I II. I II I I I .III.I II I APPROVED APPROVED WITH CONDITION(S) DISAPPROVED T A I S E ATTAQWENT WITH CONDITIONS) I N I PLAN REVIEWERS NAME �gQ��(/ DATE Q -'I I I I I I I I I I I I I I I I I I I I I I � � TI 1 fT I I flTTffTTlTfff�71TT1 I I I I I I I II 1-77-177TTII iAPPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF I 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 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I I 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.- APPLICANT'S SIGNgiIHIE: YLA 7//EJ TITLE __�_ r/�/1/YO//TI�ATE3�r I 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 7A 1T ERI \/ Address Z8 3 L-vyj4 A! & c>R Phone #_ /D�Y) l�� / RANCI+th OoRnoua , C Signature 4 64 rAk� iL��.�.45��. 915-7 y Z v - • EH230038 (revised 1/31/02) 1