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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3" 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 />----------------------------------------��n_ JE4e 41 n----537- q3 % <br />+-----------------/-�-�-----------n ---+ <br />EPA SITE # 1•Jl ---'/ 7 A- 5. - I PROJECT CONTACT & TELEPHONE # <br />�ll�� �,�ss 1l L -------- ------------------- ---- <br />+------------ j /� ]� I r 1 <br />F FACILITY NAME-�-j <br />- 1 D - - �C=�,�-/z j/�/% ------ -- PHONE-#-/ J,� _A +--------------L j� CJJJ_- ----- azarWLl TSI -1 <br />1 C 1 ADDRESS 1 A�/�---- L--� �L,L-� Y C-------- <br />_Lf-1..C1---=JL� <br />SS!! L/ <br />-------------- <br />L 1 CROSS STREET <br />I +----------------------------------------------- ------------------- <br />----------------------------- <br />------------ <br />1 T I OWNER/OPERATOR - ' <br />P ONE # <br />+-------------, - Yfte- <br />------------- <br />---- <br />C CONTRACTOR NAME ' <br />�t/i lY_ y�/C - PHONE-�7y <br />0 +-----------A---- - - -- - �----�-r--= ------------CA LIC------ -- - �` -- Jv I I�d----- <br />N CONTRACTOR ADDRESS ' CA LIC # CLASS � , <br />T +----------- -/��/--- /-� - �JJL��/J/�Jj—% l/�J,f� — --------- 1 � ��� <br />T <br />WORK.0 <br />R I INSURER --- L L�[_-- `�C�•R'1_"J6W- — ��+- � ---------------+-------OMP_# � � _1l G_✓��,,L_Q�j <br />C OTHER INFORMATION <br />T-------- — —------------------------------------------------------------------------+-------- -------------------- — — <br />O PHONE # <br />PHONE # <br />-------'-----------------------------•'----------------------- -- -------------------------- <br />TANK D # TANK SIZE CHEMI CnpL`� p LY/PREVIOUSLY DATE UST INSTALLED <br />39, , 1 ,� �1652Q f 1�.1 �e7rane�l <br />T 39- `Q',• 1 <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39- <br />P <br />L APPROVED X APPROVED WITH CONDITIONS) DISAPPROVED <br />1 A 1((S"EE ATTACHMENT WITH CONDITIONS) M� <br />1 N PLAN REVIEWERS NAME w�r� litJ 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 IA." <br />APPLICANT'S SIGNATITLE L[{y lL�l! ✓� v/� DATE 7 /� 4 ! <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 Address Phone # <br />Signature <br />E H230038 <br />(revised 1/31/02) <br />1 <br />