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Jul 07 06 09: 45a Jeffrey C. Henley 714-7q9- 1499 P, 9 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE.3R0 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 REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +--------------------------------------- ----------------------------- --------------------------------------------- <br /> , <br /> ------------- r?� <br /> EPA SITE # - PROJECT CONTACT & TELEPHONE # L. <br /> +---- ---------------- - - ------ ------------------------------------- ---c' 1- � ' - --------------------- <br /> - ----- - --- <br /> ! F 1 FACILITY NAME PHONE # 3 <br /> - - - <br /> _ <br /> --- ---------- -- -------------- -- - --- <br /> -----------------------------------------_Lpk t O <br /> � Bt$ t-t�-i 1-�i�c l_ <br /> C ; ADDRESS Z-rj-7-I S 'F(��->`1,' <br /> I ---------------------------- <br /> L <br /> --------------------------L I CROSS STREET <br /> I +-------------------------------------------------------------------------------__-------------------------------------. <br /> T OWNER/OPERATOR 1 <br /> PHONE <br /> Y-+---------------------- LC.+�-----+--------------(--------------------------- -------i------ -8(£� _ -tt ±----- <br /> C CONTRACTOR <br /> ------------------------------------------------------NAME -T- Nf_ PHONE-# � <br /> 0 + 1-� -----� ---- - L <br /> ----------------- ----- <br /> N 1 CONTRACTOR ADDRESSq I%-'s ���5 1 1..__ ---------------- LIC # ---j-4 0-1_�5__-_----S <br /> RINSURER <br /> --- WORK.COMP.# <br /> A - �- �EjM�s__=, y�ys __ `��'S�__________________+__-___________L� �_�_.SS-__-----7- <br /> C OTHER INFORMATION <br /> ------------------------+--------------------------------- <br /> O PHONE # <br /> R +---------`------------------------------------- ---------------------------------- <br /> PHONE # <br /> ------------ -------------- --- DATE UST INSTALLED <br /> TANK IDS#' TANK SIZfi CHEMICALS STORED C- Y/P , <br /> 39- �� '� tom`-Ike.►Y <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> „' ,r-P i 'WITH'CONDITIONI(S) ,DISAPPROVED - <br /> L f APPROVEDAPPROVED <br /> ( ATTACHMENT WITH CONDITIONS) <br /> PLAN REVIEWERS NAME�� \�l` 11 <br /> N I1 DATE �,,, 1,,, „ <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 FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> , <br /> APPLICANT'S SIGNATURE: TITLE DATE <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 responsibility for the billing by signature and date below. <br /> Nam6Ls`n ,ot�,,�s 4�Address 4 1(eS Naa s r���Sr 1 . hone# <br /> Signature <br /> EH230038 <br /> (revised 1131/02) <br /> i <br />