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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 /> EPA SITE # ; PROJECT CONTACT & TELEPHONE # <br /> r <br /> F ; FACILITY NAME , <br /> PHONE- ;_ # '4 e�' <br /> r L � ' <br /> C : ADDRESS � r 6 \ ' <br /> __`LC��1 t I�Y- --------- tir="_��1 t_r_� -i ----------------------------------------------- <br /> L I CROSS STREET <br /> I +----------------------------------- <br /> T ; OWNER/OPERATOR , - --; PHONE # <br /> Lj� <br /> -------------------- --- -- ------ ------------------------------------------------- _ <br /> C ; CONTRACTOR NAME_-.�i i ��,�'i-� ; PHONE # <br /> 0 +---------------- L1 �1�--`1 --- -±----------------------------------------------------- =------� f <br /> N CONTRACTOR ADDRESS i I`Y`\ �r• �� ^' CA LIC # F "ter CLASS11) (' <br /> R INSURER �a r ! ; WORK.COMP.# <br /> A ---------- ----�y------------------ +-------------- - - <br /> C OTHER INFORMATION <br /> T +-----------------------j------------------------------------------------------------+----------------------------------------I <br /> 0 , PHONE # <br /> R +------------------------------------------------------------------------------------ <br /> PHONE # <br /> ---------------------------------------------------------------------------------------------- <br /> TANK ID # K SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39 <br /> T 39- <br /> A 39- <br /> N 39- <br /> K ; 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <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 /> r � <br /> f � s fl <br /> APPLICANT'S SIGNATURE: `l ice' ,,�.'��.."�..��� TITLE `�1/'fa��i.�i�L� j%/•+��SA'1'fi <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 /> Name ►l"2c;y1;- 1140 Address aa'., i S Sfi c' ��ilG/'^ Phone# 6 Ict"D Y'- <br /> Signature <br /> '-Signature Jill , J J&, i(v-L1) <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />