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May 06 06 03:04p Mike Dotten SAN JOAQUIN COUNTY 209-533-2650 p.1 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 REPAIRIRETROFIT ,_,_UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT ----------------------------------------------------------------------------------------------------------------------------------, I EPA SITE # ; PROJECT CONTACT & TELEPHONE # I ------------------ --------- -------------------------------- A? 1 FACILITY NAME{/� + I`,.- � 6 -'EA W/^�� nE50 M A -Rt W A i..�P7HyON-EI # S -i - 13'�) I + ADDRESS------"- __I1_` --r---- A4 Bl'r[� ---D --#--S G�` 1 V N__ CA ------------------------- t-------------- ---------------------- -- ------------- i CROSS STREET 15IIv �� r I}----------------- Y OWNER/OPERATOR M i �.€ S P �. PILONE # 9${ "SI C 1 CONTRACTOR NAME A t -L E0t--PCri � C i PHONE # o+-------------------------------�- -----------------------------` N 1 CONTRACTOR ADDRESS t�-L5�____6 " ' Mcup Ck� LIC # {pZ�J-1 i CLASS T }�{_________________ -----------------_._____ _--_.-_--_-_--__-______-__--»_._-----_-_-__________-------_-______---__i R 1 INSURER A M =. X t �}-: S A ; WORK. COMP. # t '1 g 70 9 q 06 1 C OTHER INFORMATION 0 I : PHONE # 2-0q—S3Z-7320 R}------------------------------------------------------------- --------------------------+--------------------------------------- PHONB # 1 " -1 (08 - 73 20 ------------------------------------------------------------ --------------------------------- TANK ID # TANK SIZE ; CHEMICALS STORED CURRENTLY/P3EVIOUSLY ; DATE UST INSTALLED T 39- A 1 39- N 39- K 1 39- 39- i 39- 1 .,..,.,.....11..,... .. ..,.,...,II....., ..,.,. ....II. ' APPRO PPROVED WITH CONDITIONI DISAPPRO•JID �•�1 A 1 ATT ANT WITH CONDITIOP J N 1 PLAN REVIEWERS NAME! DATE +^--I' ............. . .. APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAC] JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RV -.ES AND REGULATIONS OF SAN JOAQUIN COUNTY, SNViRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWU40 : "I CERTIPY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SRALL 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 COMPSNSATION LAWS OF CALIFORNIA." , APPLICANT'S SIGNATURE: -;fat 66->� TITLE 7 R, r n �u DATE 6% ------------------------------------------------------------------------------------------------------------------------------------- BILLING INFORMATION: Z �' 19(,?1) S" sll-� 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 M I V— 1 P O TTI � Address (-7 -7 5-nB TTIEF C Ue Phone # 532 -752-D Signature ,, ��` ' 1�v S 6 PQ o RIR CA 9f370 e 1 'YiS E H230038 (revised 1/31/02) 0 t � �