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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 FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: <br /> _TANK RETROFIT X PIPING REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +----- ---------------------------------------------------------- --------------------------------------------------------------+ <br /> I EPA SITE # ; PROJECT CONTACT & TELEPHONE_#_ P-\/� S 7j416-4,-7—t,400 --__i <br /> I +------------------------------------------------------------------------- <br /> I F I FACILITY NAMEAP-Co - -- ------�------ ----------------- <br /> _9( I 0 D---------- I PHONE # ; <br /> ' A +---------------------------- <br /> C I ADDRESS 75 S P/Y 1 +L2SOLI AKS IL A� <br /> 2 57 D r <br /> ' <br /> L I CROSS STREET <br /> i <br /> ---------------------------------------- <br /> T ; OWNER/OPERATOR PHONE # <br /> I-Y B P WES i 00 -1,i PLDW O-rS LAG <br /> --+------------------------------------------------------------------- <br /> --- <br /> +-------------------- <br /> -------------- - - -------------------- <br /> C ; CONTRACTOR NMEPxoNE #I /JVi2 )4MiFn7-Al-- S /5TH57 157,7 --------- <br /> I N I CONTRACTOR ADDRESS 4 3 td., NEV/LLC 57CA LICpCLASS .458 14A� - C-lb <br /> ----- - -------------------- - -- ----- <br /> R <br /> INSURER9�1,KC 5;09, FNl T•z- ImS ; -----------012 ODD©IO_SO3_ <br /> fc /t <br /> C ; OTHER INFORMATION <br /> ---------------------------------------------------- <br /> I , PHONE # <br /> I PHONE # <br /> +--- „ --------------------------------------------------------------------- <br /> TANK IDS# TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED <br /> 39- <br /> T ; 39- <br /> 1 A ; 39- <br /> N 139- <br /> I K 39- <br /> 39- <br /> 39- <br /> P <br /> L ; APPROVED APPROVED WI gNDI ON(S) DISAPPROVED <br /> A ; ATT C ITIONS) l <br /> N ; PLAN REVIEWERS NAME DATE J <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 /> APPLICANT'S SIGNATURE: / _ (/J� TITLE &-H e-QQ,2D DATE 3IZ3/0 I <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 parry must acknowledge this responsibility for the billing by signature and date below. <br /> iii ErlVis210AdA4Fx1TAL 143 id. MEvrLLF 5,—, <br /> Name 6Y:5r&-M5Address CRA-r &6 CA, 92 5 Phone# 7/,1I5&7 6400 <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />