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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 _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT --------------------------------------------------------------------------------------+ I EPA SITE # I PROJECT CONTACT & TELEPHONE # ---------------------------------------------------i F I FACILITY NAME / _ Q 1 PHONE #� �_�� -X I I lnJ :J A --------------------�`�------- ----------�---------------------------------------- 1 I C I ADDRESS ! � L-- - G--- C�/ Q --------- 1 j 117, I 1 ADD --------------------------------- ----------------------------------------------------------------i 1 I L I CROSS STREET- /1/�if�1 -,� 1 T { OWNER/OPERATOR 1 1 PHONE # �� IY I ------Y�C ----------------------------------------1 I C I CONTRACTOR NAME /fO >r-�O,tJ ee GG 7.we/G I ---------------- � PHONE # 1 1 0 +------------------T --------------------------------------------------------------------------------- 1 ------ ---- CLASS N CONTRACTOR ADDRESS v' i3aX �� 3 1 CA LIC # LfS�3 I------ "J-C R I INSURER -G f., ��71�-r' �, �(_- ��/f�� I WORK.COMP.# - IA I-INSUR -- � - ------�- --------- --- -�1- --- ----------- - --------------------I --------- -- ----- --- - --I I C I OTHER INFORMATION I -------------------1 ------------------1 --------------------------------- 1 T +-------------------------------- - 1 PHONE # 101 1 R +-------------- ------------------------------ 1 PHONE # 1 1 +___IIIIIIIIIIIIIIIIIII1111111111111-------------------------------------------------------- _--- _--------- _-------------- _________I { 111111 11 TANK ID #II 1111 111 TANK SIZE 1 CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED I I T i 39-- A 9-A I 39 N i 39- K 139-_ 39' i 1 i + i13911111 iiliiiiiiiiiiiiiiiiiiiiiiliiiiiiiiiiiiiliiI11111111111iiiili111111iiiiiiiiiiiiiiiiiiiii Pii I I L I APPROVED APPR ED WITH CO ITION(S) DISAPPROVED i A �j (SEE A A WIT ONS) I N I PLAN REVIEWERS NAME > DATE ,I N1J t +---IIIllill1111111111111111111111111111111111111111111111 111111 111111 1111111 illllllllllllllllllll Illlllllllllllllllllllllll I 1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN IN COUNTY O ES, STATE LAWS, AND RULES AND REGULATIONS OF 1 I SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. 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 1 I1 1 BECOME SUBJECT TO WORKER'S COMPENSATION LAMS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I I FOLLOWIf:G: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO 1 I WORKER'S COMPENSATION LAWS OF CALIFORNIA." I 1 I 1 1 1 I � I APPLICANT'S SIGNATURE: < TITLE / J '�/' DATE I -- --+ •� Citi+©�\\til=y!� �iF �Q�y�1�.L /�-T,� 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 7iyo, /��' 1'0'� Address„��, d'3� .��i�� S Phone <;2e � � Signature JE EH230038 (revised 1/31/02)