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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 3PO 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. IN PERMIT TWE BELOW: TANK RETROFIT PIPING REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT + -- -- - - -- -- - _ _ _ _; PROJECT CONTACT 6, TELEPHONE 4 _ __ _ 0cAM� - -- - - -- --- - EPA � - - EPA SITE # - _ _ _ ✓_ i prt �sa L( _ - - - - - - - - - -- - - - _ PHONE # (a F I FACILITY NAMEf _ ___ _ __ -- ---- _ _ - - -- - -- - _ __ _ _ _ - - - - -- - - --- -_ C I ADDRESS j- - I I E._ '-�r _ w�Y - -- - -- - ---- -- -- -- - - -- - --- - --- - - - - - - - - - - Is - - ---- -- -- - -- - - - --- - - ------ ---- - -- ------ - - -- - - -- � II +_ __ _ _ __ _ ___ _ __ Q L I CROSS STREET _ _ _ ___ _ ___ _____ ___ ___ __ __ _ __ _ ___ _ ______ _ _ ___ _ _ _ ___ _ _ __ __ __ _' PHONE # 2 i Y i OWNER/OPERATOR � � ^ E''�OI _ � I jd � 6, ZZ 7y2 --- I PHONE # &pz & qZ (•O R(-87 + II C CONTRACTOR NAE r ` (A� co J qrf 10=1 _ O ___ __ _ __ _ _ ____-____a_____7__9__7_ _�_f_s_____S___ _____ ___ _ _ _ _ _ _ _ _ I _cLA_ s_7 sfAD +- --- - -- -- - - - - CA LIC N CONTRACTOR ADDRESSS r AVEM _ _ _ _ - _IELLI T +_ _ __ _ _ _ _ _ _ _ _ __ __ _ _ _ _ _ _ __ _ __ _ { WORK. COMP . # R I INSURER ' __ l_T�TE� v_ _ ___ ______ ____ _ _ ___ _ __ __ __ _ _ ____ _ __- --- -- - -- - - - A C I OTHER INFORMATION PHONE # 0 1 R +__ _ _ _ _ _ _ _ _ _ _ _ _ _ - -- - - - - __- - - - - - - -- - - - - - - - - -- - - - - - _ I PHONE # _ S__STO _ __HOCURRSNTLY(PREVIOUSLY _ _ _ _ _ __ _ _ _ _ TANK SIZE I CHEMICALP.ID I DATE VST INSTALLED ' - _ _ IIIIIIIIIIITANKIIDIkIIIIIIIIIII � _ _ _ _ __ _ ___ _ _ __ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ I I I 139 _I { T iA139 I N 139- I I i K i 39- 11 39 I 11" it. it lilt lllllliiii ilillllil Iiilii { iiiliiiili P � IIIIIIIIIIi illllilliiillliilllll IH ✓ APPROVED WITH CONDITION (S) DI SAPPROVID �/ t L I -� APPROVED 7 A I ( BE ATTACHMENT WITH CONDITIONS) DATE i N I PLAN REVIEWERS NAME - iililllll4liIIIIIIIiIIIIIi IIIIIII { , I � I IIII . . IIIIIIIIIIOF IIIIIIII { { IIIIIIII { I � IIIIIII { I { IIIIIIIIII � III � III { IIIIIIIIIII � III � � : i I I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH EAN JOAQUIN COUNTY ORDINANCES, STATE LAWS , AND RULES OLLAND REGULATIONS SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT . OWNER OR LICENSED AGENT ' S SIGNATURE CERTIFIES THE FOLLOWING : " I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSVED , I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER IE TO I I SHALL EMPLOY PERSONS SUBJECT TO BECOME SUBJECT TO WORKER ' S COMPENSATION LAWS OF CALIFORNIA . " CONTRACTOR ' S HIRING OR SUBCONTRAC[ING SIGNATURE CERTIFIES THE FOLLOWING: " I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED , WORKER ' S COMPENSATION LAWS OF !M71A . " j' TITLE DATE 'I �iso+ Iate' I APPLICANT ' S SIGNATURE : ✓�� __ __ _ _ _� - - - - - -- - - -- - - BILLING INFORMATION : Indicate the responsible party to be billed for additional EHD staff time expended beyondper It pymer err coverage per tank. If the party designated below is different than the permit app ' g, prop owner, the party must acknowledge this responsibility for the billingnby signature and date below. Name Address (v/SE p �� Me nm*45 �f g73Phone # 9Z 7Y87 Signature °— EH230038 (revised 1 /31 /02) i