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SAN JOAQUIN COUNTY OCT 2 3 2003 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304EWEBER AVE,3ROFLOOR ENVIRONMENT HEALTH <br /> STOCKTON,CA 95202 PERMIT/SERVICES <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 /> { I EPA SITE # - -- -----, PROJECT CONTACT & TELEPHONE # N kv t, 9is-AA- 111 !2 1 <br /> I +----------- --------------------------- <br /> F I FACILITY NAMEA �� AM1Pti. I PHONE # <br /> 0 { <br /> C { ADDRESS �c1 bQ, aF+►� Ani ti N u-T D1u <br /> iI +--------- ------ --- ------------------ --------------------------- , <br /> I L I CROSS STREET P 'b <br /> I +---------------- <br /> - <br /> TOOPERATOR { PHONE # <br /> Y l <br /> � w ST C,a�ST p n o o�cTS,_ Cc-------------------------------+----1- 4------------------------------ <br /> C <br /> ----0-s ----------------- <br /> C I CONTRACTOR NAMES T LjF AV p 2 C 0 h S V(�T t V M { PHONE # 6 a p 5 ' <br /> I0 +----------------- -�_ - ------------------------ ----------------- -4------------------------------- 9 Q'------ ---------I <br /> { N { CONTRACTOR ADDRESS I ll �� S` ►4�L C- { CA LIC # I 1 13 , CLASS <br /> T +------------------- +�---- --- -- ------------- - ------------- -------P-�'A-- -4'-- <br /> ---- 40000zog5 <br /> { R { INSURER_5N WORK.COMP.# <br /> �TflT�--- c.� Q----------------------------------------------------' --------------------------�'� - ------{ <br /> { C { OTHER INFORMATION I <br /> { T +-----------------`------------------------------------------------------------------+---------------------------------------{ <br /> I 0 1 I PHONE # { <br /> R +------------------------------------------------------------------------------------+---------------------------------------i <br /> { I I PHONE-# <br /> --------------I <br /> ----------------- <br /> +---{ iii {III{I{{III1{III{{{IIII{IIII------------------------------------------------------------ - <br /> { { TANK ID # I TANK SIZE , CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED <br /> I { 39- I { I <br /> T 139- I { I <br /> A { 39- { I I <br /> i <br /> { N I 39- I { <br /> K139- { I l I <br /> { 39- i { <br /> { i 39- { { I { <br /> -P-iII { IIIII{{{ii {III{IIII{{ { {ilii{{{{{{{ {i{{{{i{I{{{{Ili{ I{ii{i{{{{{I{i{{IIIIIIIIIIIIIIIIIIIIIIIIII { III <br /> I L { APPROVED APPROVED WITH CONDITIONS) DISAPPROVED ' <br /> I A { (SEE ATTACHMENT WITH CONDITIONS) { <br /> { N { PLAN REVIEWERS NAME DATE { <br /> { I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF { <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S.SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY { <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 { <br /> 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 /> { WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> i <br /> i <br /> I <br /> Q/ l <br /> APPLICANT'S SIGNATURE: TITLE /!y,/�� DATE <br /> +----------------------------------------------------------------------------------------------------------------- -----+ <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 /> Name bAti 4uTy,�-, ETA- Address)I)Q t. Ttf(kn, L.A.C,4 q6,,51 Phone#113-44S- 39 t 2 <br /> Sig nature, /� <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 . <br />