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. X • SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3"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 RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT EPA SITE X PROJECT CONTACT 6 TELEPHONE X N& ��t�, t!_ _3�i2 F : FACILITY NAME 0 2(. __-A M PA, ; PHONE X 1L ---�---- --------------------------------- -- ---------- -------------------------------- ----- 1 C ; ADDRESS I a Si�)_W`L'>-N-L-? `S_________________________________________________________-_______________} I +_________________ _ , L CROSS STREET __________ PHONE X T OWNER/OPERATOR -_- -__ B? (A, EI rl (X70- i3c� + Y Co a s� QA - -- —_-j l<< --I------------------ - S. � WfA L EQ C-;�,T IAC F -~` -; PHONE X S6�"�U_ O----------- & -1 - I C CONTRACTOR NAME fa_i _ __ _______ ____ _____ _______________ _____________ ASSA N ; CONTRACTOR ADDRESS/ V I t i�irz UC �I�I�AI.-^1�y��[; CA LIC p__� ,�1'l� ; CL------ aZ} Ip W i, l ______CLAS___ R 1 INSURER WORK.CQNP.Mgb7oouuaSi-� S T A7 E_r u N a------------------------------------------------�--------------------------- -- A ______________ 1 C OTHER INFORMATION - x ; Ti PHONE X 0 ' PHONE X -------------- _________________________ _ TANK ID X TANK SIZE 1 CHEMICALS STORED CURRENTLY/PREVIOUSLY OA-- UST INSTALLED ' 39- T 39- A 39- N 39- 1 K 39- ; 39- P _ PROVED WITH CONDITION(S) DISAPPROVED APPROVED AP )SEE AT A �L.e� ny ATTACHMENT WITH CONDITIONS) ; N �; PLAN REVIEWERS NAME TO" I DATE OAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES 2;U REGULATIONS OF APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN J SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FC:.LOWING: "I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANNSW IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGHA--'IRE CERTIFIES THE 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.��//f Poe-o A APPLICANT'S SIGNATURE: TITLE A V C•�'T DATE GS/:�, oy +__________________________________________________________________________________________________________________________t_____ 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 Address Phone# Q Tlui �� x� or 9" ,��7/a`VJ- . �erm�X i3 ci f f(X u�X1�� u- '� '`-'- 2 x / 4'�a r-hn.'o n0 �f[aa�'X e / eoto-u�/ /ee� %K ire00 fe-'rk . d 0S.Z00,?6otg �5eeFh-L�Le...epi',c�,.7`�ora�Proo�eysu(pµ..-.fa-..o'� / Z) v_. - -- i.I-. _ d,17- r..._ .-_ _ _ .1._ _.._dou -1Y �