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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 38O 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 RETROFff _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT A atva-lcl <br />1 1 EPA SITE k -------------------------- PROJECT CONTACT & TELEPHONE #-M�,, t WkILQ x,,44 <br />+___________________ _ �+pt��a.13 _rQo3S; <br />1 <br />IF 1 FACILITY NAME ���pp ______________________________________________________PHONE k_ �4 _ 47 a k� OQ_______i <br />I A +_FACILITY________ ].. ,1 Thies' /2 .I^�y ��g �-/ /' '�/�/� NE # <br />C ADDRESS �4-a.S' IV 0 • `^_ScS_3"S.P__•_`y_ ""4�"_`L __---�---- �SL"�-------------- <br />i L 1 CROSS STREET Ike..1+r�'.I -�-1 <br />II -------------- __________________________________________________ <br />T 1 OWNER/OPERATOR I PHONE # <br />�teoutbv by v!LL tl I �4-4iJ--y600 <br />Y I I <br />I ---+--------------------------ice Sy--�---------------5-�,------------------+---------4--8------------------------1 <br />C CONTRACTOR NAME QQ�� " tWlCiA 'S G� I PHONE k O <br />1 0 +___________________`-4__________ __-________-__ SSSS SSSS_ <br />/���_(___'f___p_______________________[_�_-__L___ <br />i N 1 CONTRACTOR ADDRESS &n () C�uivea __L7Q'i.a_ Sa �T__ `S7r� I CA LIC # I�8 r y l�. 1 CLASSY /�� ..L <br />IT +_____________________�__ ________ _ _______________________________G______________ UL- —----0�1 <br />—"'------ <br />R <br />'i - <br />R i INSURER IY---------------------- <br />C <br />NORKCM rryi�-I A '___SURE_____ Y1�t_____________________________________________________�_----L _=___�____ <br />C <br />1 <br />: OTHER INFORMATION <br />1 0 1 1 PHONE # <br />------------------------------------------------------------------------------------------------------------------------------ <br />I PHONE # <br />TANK ID # <br />39- <br />T 1 39- <br />I A 1 39- <br />I N 1 39- <br />I E 1 39- <br />39- <br />39- <br />P <br />1 L 1 <br />IAT <br />N i PLAN REVIEWERS NAME <br />}---'111 �, x .................111,,.. <br />TANK SIZE 1 CHEMICALS STORED <br />1 DATE NET <br />WITH CONDITION(Skk DISAPPROVED <br />T WITH CONDITIONS) I /� <br />DATE / <br />APPLICANT MUST PERFORM ALL NONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAM TOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGMA= CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN.THE PERFORMANCE OF THE WORE 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 TRE <br />FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSURD, I SHALL EMPLOY PERSONS SUBJECT TO <br />I WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: 4k <br />BILLING INFORMATION: Ir CCU <br />TIME <br />-I i <br />jvc. <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 I" IAeTuJ V, WEELT4114Ad Address ✓xb0 W'ttk pine, Eau ke ldl :z Phone # 4bV`.2j3-WF <br />Sinnature I'L1XLccL&V -i.txt;b � iv <br />'�- Selr�t�o��e``S-(-ri'Ftliv� Si(Ste.�uS <br />EH230038 <br />(revised 1/31/02) <br />