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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 3RD 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 If i PROJECT CONTACT & TELEPHONE # i {+-------------------------------------------------------------------------------------------------------`------------------{ F { FACILITY NAME L(- �..}- (� p "_i/��,,,\� j PHONE-# .....�---- IA +------------------- ------ y------ -)Ai---------------------------------------- ----- 7 ----[ { C I ADDRESS �- '--- ---�- — -- I I «------S 1,etfZ_------ �' -- `---------- - ---------------------------------------------------------------I { L I CROSS STREET C� ,v ✓--�---- --- I I I ----------------------------------- -------- --------------------------------------------------- I T OWNER/OPERATOR { PHONE # i �- �A,1_ 5 --- Imo_ _%-----------------------------------------+---------%--n--�— ---- ------i { C { CONTRACTOR NAME I PHONE ! N I CONTRACTOR ADDRESS % �. I CA LIC # i Ir � CLASS � T-------------------- -- -------------]^-1------J-"1dJa°-------------------------------------------------------------i I R I INSURER WORK.COMP.# AI------------------------------------------------------------------------------------+----------------------------------------i C I OTHER INFORMATION {-------------------------------------+---------------------------------------- i PHONE # RI------------------------------------------------------------------------------------I PHONE -#--------------------------------I I IIIIIIII{IIli{{{IIIIIIIIIIillll---------------------------------------------------------------------- - ----- ------ - -- - TANK ID # I TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED I 139- I T { 39_ I { A I 39_ { IN 39- K 9 K 39- 39- 39- I I ITI 9 39- IIITI L I APPROVED APPROVED WITH CONDITION (S) DISAPPROVED A EE ATTACHMENT WITH CONDITIONS) N I PLAN REVIEWERS NAME 0 111 DATE � } Z(/ �G i/ +---i{1{11 111111{i1{111 ill I111li ;111111 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF 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 ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE 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." i - I� I APPLICANT'S SIGNATURE: mil G. TITLE al _ DATE I +------------------------------------ / -------- ------------ -------------------------------------------------- ----+ 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 �P�2/ C �4 Phone # Signature EH230038 (revised 1/31/02)