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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 390 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 REPAIRIRETROFIT --_UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT ___ _________ _____ _________ ____________ ____________ ____________ ____ 1 I EPA SITE N I PITO.TECf CONT'ACf A 113,HPh10NE N I I + / -- ---------------- — -- -------C------- /✓��7 — I F I ---- --------B ll 1 =f------------------------� F---- N RS 9--g��J_ C 1 ADDRESS 1 I -------- ------� -_711Z -- --- yr 'p✓'----- ---�� ---- - --------- ----- L I CROSS STREET 1 - 1 I +______________ _ ______ _____________________------------ - --- ----------- ------ ---------- - --- -------------------------------- T GWNB12/OPBAATOA MGM It IYI I ---+-- eSA----�J- 1 � _Ca 1s/1----------------------------------- I C WNTRACIOR WANE "GONE N 10 ----------- ------- _yl i��.- - ---- 1��'--ri �----- -------- --------- ---ZO9 532__133- - I 1 N I WNTRACTOR ADDRESS I T +----- -- - L✓bk l _ /CS I LIG &_ _66 /6611 1 Q S G-/a fJ R I INSURER //� �'].1 A I _________L�lf�17_ r _ .1 yLt<'ILi�QI____[1( [-'_"'!� /i I WOR------ k I C I oTHEE INFORMATIO - ---- T +_________ _ __ __ ____________ _ ______"_ _________________ _________________ I 0 1 I PNONE X I R _________ __ _ __ __________________ __________ _________________ _ ________________________+_ I PHONE n +--- IIIIIIIIIIIIIIIII111111111111111 _ _________ --"- -------"_-- -- ------_""-------- - -- ---"--_---------------------____ 1 TANK M H I TANK SIZE . �g� cNsrOREO 1 /�// uI CORnPtmL /PREv�aus r gq�ssT N T�L�ED / 1r N^, LGNrB.r_"r6P�4 Ibj^ /.Jl `Y �r7I. 17139- I I I I A 139- 1 I I I INI39 I IKI39- I I I I 1 39- I 1 39- +- 111111111111111111111111 9---- 11111111111111111111111 I I I I I I I I I I I I I 11111111111 lyl'I I I I I I I I I 1111111111111111111111111 I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I PII/ I I L I AP VED _ APPROVEDWITH OGNOIYION ( )) _ DISAPPROVED. ��JI I A I (SEE ATTAC ry WI1H / y'`//r� DATE N PLAN REVIEW8ILS NAME J L_/ +--- IIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIII IIIII 1111111111 I I 1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN SOAQUIN COUN Y ORDINANCES , STATE MWS, AND RULES AND REGULATIONS OF I SAN JOAQUIN COUNTY, ENVZROMA@TI'AL HEALTH DEPARTIdENT. OWNER OR LICENSED AGENT' S SIGNATHER CERTIFIES THE FOIdtATING: "I CERTIFY I I THAT IN THE PERFOMANCE OP THH WORX FCR FkIICH THI9 PERMIT IS ISSUED, I SHALL NOf PSIAY ANY PRRSCN IN SOIX A MANNER AS TO 1 I EECCMfi SUEIECT M WORKER' S COMPENSATIW MWS OF CALIFORNIA. " CONTRACTOR' S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THR I 1 FOLLOWING: "I CERTIFY THAT IN THE PERPORNANCE OF THE WRK POR NHICH THIS PERMIT IS ISSUED, I SWaTT EMPLOY PERSONS EOH.IEGI M I WORKER'S COMPENSATION LANE OF CALIMIZNIA.. " I I I I APPLICANT'S SIGNATURE: ' TITLE 6 L1' x u DATE -J V 1 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_ �A � /G�}- �(LAI re'ssyJ &13��_ _Phone # LO9 S�S8 6+33 /311 --