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SAN JOAQUIN COUNTY
<br />ENVIRONMENTAL HEALTH DEPARTMENT
<br />304 E WEBER AVE, 3RD 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 k PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT
<br />--------------------------------------------------------------------- /1 % -+
<br />EPA SITE # PROJECT CONTACT 6 TELEPHONE #w A Y_ Ami/ /SS/
<br />F ; FACILITY NAME ' _ r PHONE #
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<br />CI ADDRESS ��y� �m EXi�ca�; O
<br />L CROSS STREET
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<br />T OWNER/OPERATOR PHONE # ,
<br />Y — ------ -� ��-- � -- -- --- --� , ---- --1Ar l g ------+-------- 2� 9r �s/ _ /Ss l '
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<br />C CONTRACTOR NAME I PHONE #
<br />D +----------------------- Dorn 1---P�f'`---C®r,�,�n -- --ZD --33 %- J3F� ----i
<br />------------- -----
<br />N ; CONTRACTOR ADDRESS aQG � �R- CA LIC # _ _---CLASS
<br />_-----�/33e -6 --�_--
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<br />1 R 1 INSURER WORK.COMP.#
<br />A'-------------------------------------+---------------------------------------i
<br />C OTHER INFORMATION
<br />T+-------------------------------------------------------------------
<br />0 1 1 PHONE #
<br />-----------------------------+----------------------------------------'
<br />1 PHONE #
<br />+---'11'I' 1 1111 1 1111 1 --------------------------------------------------------------------------------------------
<br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED
<br />39-
<br />3 39-
<br />A 39-__
<br />1 N 1 39-
<br />K 39-
<br />39-
<br />39-
<br />+---IIIll.... " " 1 11,11111111 11,,,,,,,,,,, ,,,,,,,,,,,,,,,,,
<br />1 P
<br />L APPROVED `� APPROVED WITH CONDITION(— DISAPPROVED
<br />A 1(SEE AT CHMENT WITH CONDITIONS)
<br />I N 1 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 />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 />COMPENSATION LAWS OF CALIFORNIA."
<br />APPLICANT'S SIGNATURE: TITLE /CC da _t( DATE /O -✓O
<br />+------------- --- ------------------------------- —
<br />BILLING INFORMATION:
<br />, , THAT IN THE
<br />WORKER'S
<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 owner,
<br />the party must acknowledge this responsibility for the billing by signature and date below.
<br />Namej�l�aQt_ %, 6S_4- IAor,_�c�Add(r�eys^s �P. Phone # ee-?,57-
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