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1 SAN JOAQUIN COUNTY 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 REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT --------------------------------------------------------------------------------------------------------------------—-----------+ EPA SITE # ..Ac o0o dZ7 6 4-91 1 PROJECT CONTACT I TELEPHONE # pA U L A . ( r K�L�IZ CM�)53-�.9(a F FACILITY NAME---------------------------------------------------------E Co N`+,) LU 9 E .TUN_� ____________ PHONE # (20li� ___ ,____ ___________I A +______________________CQ____/____________________-_____77_'�____________________________________--_\__v____1_J_______________________ C ADDRESS CCI-10 WF-ST LANE ';TJOC K F L�4a CA . 954 0' T + __________________________________________________________________ L CROSS STREET R R i 0 L E rA Tii 1 T ----------------------------------------------------------------------------------------------------------------------------- Y kOWNER/OPERATOR PHONE # w t W is K m.f1� (s3Q)£�� 149h- ---+-------------------- J� ----------------------------------------------- -------------------- 1 C I CONTRACTOR NAME ACC LI'T i I E PHONE #(650)952--555 k 290 10 +_________________________________________________________________________________________________________________ ___� N '; CONTRACTOR ADDRESS 3S L i N D E N AVE- II CA LIC # 762_C3-+ II CLASS 4 ii A Z RL 3 k T +_______________________________________________________________________________________ 11 R INSURER 1 WORK.COMP.# 9 2-1-116 2 11 C OTHER INFORMATION CA U L A- P i N T O I? IT'ROJ. MCS, r. II (415) 55q - 34916 I� O 1 O F I C� i A x # PHONE #(b 50)9 J z`-1(:�-3 I R + _________________________________________________+__________________ ______i PHONE # +___ 111.11 111 1111111111111 1______________________________________________________________________________________________ .1111 1111 1i 1i 11111 1111111111111 TANK JD # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED j 11 39- 1 4-4- /f'Ti_F. T 39- �1i !SOO 4��. 1 6 L 11 A 39- 1i N 39- K 9-K , 39- 39- 39- L 9-39-39-L 11 PPROVED APPROVED WITH CONDI' ON(' ) DISAPPROVED j A SEE A WITH CONDITIONS) N PLAN REVIEWERS NAME0 - DATE 11111111 11 1111111 1111111111111111111111111 111111111111111111 111 11111111111111111 ,___1.1111111 I 111111111111111111i111111111111111111111111111111 (III VIII II IIII11111111111111111111111111111111 111 11111111 111111111 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 11 11 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 1 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE 1 FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." 1i i I APPLICANT'S SIGNATURE: ,( TITLE � � ' ��• DA �� BILLING INFORMATION: MAY o 3 2004 ENVIRONMENT HEALTH PERMIT/SERVICES 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_Tsc-.ACCU-vI-'TE-----Address 9 L�6_LINDia tJ_AVE__�gOt') :--Phone#_��50)952-SgiI