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0 0 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3ND FLOOR <br />STOCKTON, CA 96202 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THEdA�L" �D�ATE 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />_TANK RETROFIT ✓ PIPING REPAIRIRETROFIT UNDER DISPENSER CONTAINMENT REPAIRJRETROFIT <br />+----------------------------------------------------------------------------------------------------------------- + <br />EPA SITE If ; PROJECT CONTACT 4 TELEPHONE $ <br />+___________________________________________________________--____________________ <br />1 _ ANNA ___________ <br />F ; FACILITY NAME F� 9/nt - r ------------ <br />j -- �•__L"__ - _____________________________________PHONE 3-----! <br />A +__________NAME______ _ J 7-) <br />C ; ADDRESS , 3�%1___LL/__�_L-J L! _ L_ -ANNA_ <br />I+---------------- -- L�Yh �b---� lfh---- __----------------------------------- <br />L ; CROSS STREET <br />T ; OWNER/OP TOR PjIONE $ <br />Y ;��� G,�����, „ ; b 3 3 �1- 3 x_33 <br />---+---------------------/-----(-------------------------------+ ------ ----- - <br />C ; CONTRACTOR NAME____ / 4M �` I -------------------------------- PHONE Q'� L/) _ L� .5 <br />O+------------ f-- ----------- '----------------------- - - -i-a y ------ ----- <br />N ; CONTRACTOR ADDRESS &L'>7 tC' -- `r _ - -�%m 3L V,) CA LIC $ CLASS ; <br />T+---------------------------- t 1?3--- yi--�' ------------------------------------------------------- <br />R ; INSURER )9 "Z—p rdi 9SLf7 ; WORK. COMP. $ 54. �' <br />A--------------- 4r'h_sf----------------' <br />C; OTHER INFORMATION 1 0&>60 )2t7,2 b rs <br />.T _______________+_________ Y <br />p , PHONE $ <br />ANNA_ __________________+ANNA___ ___________ <br />PHONE $ <br />______________________________________________________________________________________ <br />TANK ID If TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- _ <br />T 39-0 sii17 '�Y <br />A 39- ;_ !JD ' <br />N 39- <br />K 39- T"T� <br />39- <br />39- <br />P <br />L APPROVEDAPPROVED WITH CDNDITION(S) DISAPPROVED <br />A ; SHE ATTACHMENT WITH CONDITIONS) DATE <br />N ; PLAN REVIEWERS NAME <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 SUBC�PTRACTING 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 />APPLICANT'S SIGNATURE: TITLE ! /1�J//� 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 /4,+,c %1'1,'x, )'Yjel� Address /3DJ iL• ,L)�%zmlorl 1,>,,Phone # ,XPi 73)y 3 �33 <br />Signature <br />EH230038 <br />(revised 1/31/02) <br />1 <br />