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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 KelPING REPAIR/RETROFIT "* I NDER DISPENSER CONTAINMENT REPAIR/RETROFIT ---------- ----------------------+ I EPASITE # - 1 PROJECT CONTACT & TELEPHONE # R/j4-� �'��a I --------------------------------------------------------------------------------------------��-- - ----------------I 1 F I FACILITY NAME GAA,), f11,-X r1qR L•L/h:)-/-/ I PHONE # A +-----------------------------------_------------------------------------------------' -- ------------------------------i CI ADDRESS / C2 /' 3 O STf CJ C/r /c /�J�Z J- C/�TL�/C� vJ 0 ------------------ - ---------- ------------- ---- --- ---- -- L I CROSS STREET -------------------------------------------------------------------I I T I OWNER/OPERATOR ^ I PHONE # ,_ 1 1---+--------- ------------------------------------------+-- --- - -- -- ----- I C 1 CONTRACTOR NAMEG Tid / PHONE # I 0 i------- -----.-TC- --- .. .LJ-- ---�'----- C----------------------� N CONTRACTOR ADDRESS ,y ^�{ I .�� V B�//1 _7GQ� �� p�/�S CA LIC # �� 3 1 / ��f ------------------------_CLASS--- I R I INSURERy 9 1 WORK.COMP.# I A I----------!//e// L---� -- - CIF/C I C I OTHER INFORMATION i I 1 ------------------------+----------------------------------------1 0 1 1 PHONE # 1 -----------------------------+----------------------------------------i I - i PHONE # +---11111111111111111111111111111111----------------------------------------------------------------------------------------------1 TANK D I TANK SIZE 1CliAMICALS STORED CURRENTLY/PREVIOUSLY I DATE yST NSTALLED 19- 1 Q o 1Xz �/✓L I !//� 1 I I T 1 39- I -- 1 A I 39- I I N i 39- I 1 K 1 39- 39- 39- 9 39-39 Pl 1 L 1 APP V PPROVED WITH CONDITION( _ DISAPPROVED 1 A 1 n' - ! /� /� (SE CHM T WITH CONDITIONS) A3 I 1 N 1 PLAN REVIEWERS NAME I"��I'I� j/ (l DATE i +---11111111111111111111111 M !qJ 111111111111111111 1111111111 111111111111111111111111111111111111111111111111 I 1 I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF 1 1 SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 1 1 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 1 FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO 1 1 WORKER'S COMPENSATION LAWS OF CALIFORNIA." 1 I 1 IG 7�---.. /V i 1 APPLICANT'S SIGNATURE: TITLE DATE6;� , 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 -TEf/= Address 1-,,;7,30 P.4611-IC Phone #Lj-1 Signature Eevised 1/31/02