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b* ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGR* TANK RETROFIT, TANK LINING, OR PIPING REP ERMIT THIS'P�RMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: _TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR I l l i l l l l l TANK l l l l l l l l l l 1111 TANK IQ # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- % I('q — Z- Z. T 39- Tis;!"ZU A 39- N 39- K 39- 39- 39- II11 P L A PROV APPROVED WITH CONDITION(S) DISAPPROVED A _.ALTACHMENT"WITH CONDITIONS) N PLAN REVIEWERS NAME DATE2 C 1111111111111111111111 II11 illlll I I1 I II11 111111111 111 Illli I lili 111111 illi I 111 II I1 I!lIII! APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 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 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE 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." 6 17/94 APPLICANT'S SIGNATURE: BILLING INFORMATION: TITLE MANAGER DATE / Indicate the responsible party to be billed for additional PHS-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 CRISP PETROLEUM ENVIRONMENTAL Mailing Address P.O. BOX 30847 STOCKTON Day Phone Number (209 ) Signature -' 931-1828 FAX 465-3806 E EH 23-0038 �. % G.� ,C �Itc-� r-Z,z,,�� r Elv�J , EPA SITE # PROJECT CONTACT & TELEPHONE # F FACILITY NAME DDRW—MFW—SHARPE FACILITY PHONE # A C ADDRESS BLDG 5-41 LATHROP CA 95331-5108 I L CROSS STREET I T OWNER/OPERATOR PHONE # Y C CONTRACTOR NAME CRISP PETROLEUM & ENVIRONMENTAL PHONE #209 — 0 N CONTRACTOR ADDRESS P.O. BOX 30487 ST CKT CA LIC #ON FILE CLASS A T R INSURER WORK.COMP.# ON FILE ON ETLE A C OTHER INFORMATION T 0 PHONE # !i R PHONE # I l l i l l l l l TANK l l l l l l l l l l 1111 TANK IQ # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- % I('q — Z- Z. T 39- Tis;!"ZU A 39- N 39- K 39- 39- 39- II11 P L A PROV APPROVED WITH CONDITION(S) DISAPPROVED A _.ALTACHMENT"WITH CONDITIONS) N PLAN REVIEWERS NAME DATE2 C 1111111111111111111111 II11 illlll I I1 I II11 111111111 111 Illli I lili 111111 illi I 111 II I1 I!lIII! APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 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 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE 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." 6 17/94 APPLICANT'S SIGNATURE: BILLING INFORMATION: TITLE MANAGER DATE / Indicate the responsible party to be billed for additional PHS-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 CRISP PETROLEUM ENVIRONMENTAL Mailing Address P.O. BOX 30847 STOCKTON Day Phone Number (209 ) Signature -' 931-1828 FAX 465-3806 E EH 23-0038 �. % G.� ,C �Itc-� r-Z,z,,�� r Elv�J ,