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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3iD 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 REPAIR/RETROFIT __UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT +------------------------------------- -------------------------------------------------------------- -----+ I EPA SITE #Cp, -iqj (a p I PROJECT CONTACT & TELEPHONE #�/je (M;tp�/'�,�_ r 2 I D- i l- -------------------------------------------------------- F ----- -------------------------------+---- --- l �`lJ �tsf� I F I FACILITY NAME I PHONE I A +--------------- 'Gk��"'e'^ S d'� z3Z- _(q/_7„�- ------ 40'`) ? I--3 z- C ADDRESS �3- --lv�-' (r�``------- j'''.��Q----- A----------59M73_6--------------------------------------i L I CROSS STREET I ----------------------------------------- ---------------------------- T OWNER/OPERATOR-j-q_1e')Q-v1 I,V�/C• ? I PHONE �fz.9f'1 l.l. I-Y- -------l---—-�4'CII�L 1�AJ ,� �5' ---------------------+------- ��2-- [S1i U---------I C I CONTRACTOR NAME I PHONE&!z( G/ -cr-Gc1✓E rrr �--1cr —I4-T--I------------------------— 35-C-7 z8zs.. N I CONTRACTOR ADDRESS z I. G,wK,%w- D,'. 5 r A T --------------------- I�e - ______ --- LIC - 7�_g_?3v__ I_C�S ------------------- R I INSURER WORK.COMP.# ,�p O I A I--------- a _�i1M -TT-11-. ....�+ns.3�t✓�C� ----------+-------------- rJ�I- -----I C I OTHER INFORMATION T +------------------------------------------------------------------------------------+------------------ 1 0 1 PHONE # IR + -----------------------------------------------------------------------------------+----------------------------------------I PHONE # IIIIIIIIIIIIIIIIIIIIIIIIIIIII-----------------------------_---_________________-------------------------------------------- TANK _________________ ----------------TANK ID # I TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UFT INSTALLED I I 39- 10,00.0 I A^1 (►-- I (0I IT139- I I I I I A I 39- of I16 eao I�QLe 1.4.Q_ Iee I N 1 39- K 9-K 1 39- 39-_9-39- I I I 139- P I I XAPPROVED L I APPROVED WITH CONDITION(S) DISAPPROVED I A I ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS DATE 'T d +___IIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIII IIIIIIIII 111111 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIII I I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY I I 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 I BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.” CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I WORKER'S COMPENSATION LAWS OF CALIFORNIA." I I I I C_I�-Cl ` I I APPLICANT'S SIGNATURE: TITLE S DATE I I +____________________________________________________________ + _____________________________________________________________________ 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 Address_/24"2-1 br>!�.- _ Pn -_w4'e'_6Phone# 55-2 _ 1