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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 —PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> — ---------------------------------------------- ------ -+ <br /> +-----------------------------------------,-------------------PPPPPP------- I <br /> I I EPA SITE # I PROJECT CONTACT-&-TELEPHONE_# -- - - -- - ---- - - -- <br /> F I FACILITY NAME S- �- -6-45 <br /> !i ----------------------PHONE # <br /> -----'-'--------i <br /> IA +--------PPPPPP---- L 5 I <br /> C I ADDRESS �`-F- ---- --[ 11 <br /> -__------ ------------------------------i <br /> L I CROSS STREET �• <br /> --Q�X----- - �'-------------------------------------------- <br /> I I PHONE # I <br /> 1 T I OWNER/OPERATOR ; <br /> IYI S�� Jav- <br /> --- - 1 <br /> ------ ----- ---------------------------------- <br /> +------------------------- l I PHONE # I <br /> 1 <br /> C CONTRACTOR NAME <br /> I � Co n S TYi'G / '------- ------------- ---- ---------------------------------------- <br /> 0I <br /> I + ---- ------------------------------------- <br /> SSlPP c--�j -v I CA LIC # 2 rtG 4 i CLASS r7 <br /> N I CONTRACTOR ADDRE �3��/_,, �eY S`Ij y C-----------------------5-----------------------------PPPPPP --1 <br /> s[ ---- <br /> T +---------------------------- --------- <br /> 1 { WORK.COMP.# I <br /> A ' INSURER C ------------I <br /> --------------- -------------------------------- <br /> ---------------------------+----------------------PPPPPP I <br /> C I OTHER INFORMATION <br /> --------------------------------- <br /> - ----------------------- PHON----------------------------------- <br /> T I +-----------------------*- I PHONE # I <br /> I O 1 - ---i <br /> R +-----------------------'------- - PPPPPP ---- -PPPPPP I PHONE # <br /> I -i{ ------------------I--------------------IIIIIIIiI{TANKIIDI#iIIIiIIiIIIi -------- -------- <br /> ---------------------------------- <br /> TA-NK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED I, <br /> T I 39- <br /> A I 39- I I I <br /> N 139- I <br /> I K 139- I I I <br /> I 139- I I <br /> I'--iIIIIIII{{III{{IIIII <br /> II I.{IIIIIIIIIIIIIIIIIIIIIII {11111 IIIIIII {1111111{IIIIIIIIIIIIIIIII11111111111111111{�IIIIIIIIIIIIIIIIIIIIII <br /> P <br /> DISAPPROVED I <br /> ej <br /> L i APPROVED APPR WET CONDITIONS) I/el <br /> { A I AT H CONDITIONS) <br /> N I PLAN REVIEWERS NAME DATE <br /> +---I{II{III{{{IiIIIIiIII{Ii 1 { 111 I{Iili {i{i{ii {{iii{i{{i{{{{1{1{illi{I{Ii {II{I{{iii{i{{IiIIi{Iii { <br /> II <br /> 1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF I <br /> I SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY I <br /> 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 <br /> I 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 /> I <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." I <br /> I <br /> I I <br /> IA�!Y— (, He 4 DATE _ <br /> 1 APPLICANT'S SIGNATURE: TITLE I <br /> I ---------------------------- - -PPPPPP -- --- + <br /> BILLING INFORMATION: <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 <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Nam ,- Address /V �eYS/z«f J/�� Phone # <br /> Signature <br /> �� <br /> EH230038 <br /> (revised 1/31/02) - /� <br />