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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 3" 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 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATION_ .F SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING' i ._.....-. THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MARINER AS BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.” CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIF:E= :.._. FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH. THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUB P::7 WORKER'S COMPENSATION LAWS OF CALIFORNIA." i APPLICANT'S SIGNATURE: TITLE V !' C _ DATE L1 L stir 's= %�err�yc ---------------- ------ - BILLING INFORMATION: 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 46r,�� CeWS�Z I�� Address 105 CAoe;Xz-Avo ��! rii� Phone # 760/7Zi 4�2,r- �cE%�R/Sr C4 92c -,S4 Signature EH230038 (revised 1/31/02!) nmV OJr �t< j er- C� -011- ""-� TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT ,/ ----[�---------- EPA SITE # `Af /O tiVS/ti��'J i PROJECT CONTACT & TELEPHONE # •t�'l�/1Li,v e"i p�/' /IL�c c,t - /_-3 ( 9 ---- - F ------------------------ `ty�-------Q---------------------------------•--------------------------------- ; FACILITY NAME - < AJ ll 7 9 PHONE # C ADDRESS 1399__�J. _ �„y_ /G%q,VTEG/� Clf 9533 i---------------- - -•-•-------------------- I,--------------- L -- - - - CROSS STREET Ale,47W6.47-E �6R. �/V ��(-� T ----- --------- -- // --- ---------------------------- / O'WN£R/&PeftTPOR' AJ --"------------------------------------ ---- --... 1 PHONE C CONTRACTOR NAME ��IJ(�iNG�Ki�VGt �NC-----------------I_PHONE # X760 %2/'-^r�ZCi 0 ' N _(.�+NS�2JC_�iC��✓� .------------ �! �- i CA LIC # ; CONTRACTOR ADDRESS/06(',,,,0/,, (jq- -------- IL 3 39(c ------ - CLASS A E-lA Z-, C -/ o R -------------------- /` WORK. COMP.# INSURER S%77i`� („y.ryPEIV5.4r70, lA/Sd.C� -Ve6 �da/;i ' ��5__59- '-•-------------------------------------------•----- ---------------- C OTHER INFORMATION 1 0 ----------'----------------__-_•--------------------•----------•-+- 1 ------------------------- PHONE # R+------------------------------•-----------------------------------------------------+-----------•------ 1 1 PHONE # ----- --- - ,11111111111 11111 IIIII II________________________________i_______________...______________. ________________ +---ii1 lill 11111111111111111�11111�11 TAN Kg D # i ; TANK SIZE CHEMICALS STORED CURRENTLY/�i%9Wt X0506 J CIAL-Ca.Ai�v�.N.:' T'___ DATE UST _NSTA:.,I.E� I 39- d 3L iL' 6v0 !/n/LcE/fDF1/D 2Zi �CWX) C4AL ' ay -A 3 9 - SO O iO U--- V 19f-, .-- _ - N 39- i ------- K 39- 9'39 39- -39-P 39- P L i1 APPROV D _ APPROVED WI H CONDITIONS) DISAPPROVED A % 1n\ E TTACHM I H CONDITIONS) W\ N PLAN REVIEWERS NAME V� a DATE --- 11111'1 + 111111 1111111 111111 IIIII11111111111 Illll llllllll 11111 lllljj 111111111111111111111111111111111111111 11111111111111111111111111111,11111111 �,li. APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATION_ .F SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING' i ._.....-. THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MARINER AS BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.” CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIF:E= :.._. FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH. THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUB P::7 WORKER'S COMPENSATION LAWS OF CALIFORNIA." i APPLICANT'S SIGNATURE: TITLE V !' C _ DATE L1 L stir 's= %�err�yc ---------------- ------ - BILLING INFORMATION: 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 46r,�� CeWS�Z I�� Address 105 CAoe;Xz-Avo ��! rii� Phone # 760/7Zi 4�2,r- �cE%�R/Sr C4 92c -,S4 Signature EH230038 (revised 1/31/02!) nmV OJr �t< j er- C� -011- ""-�