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SAN_JOAQUIN COUNTY
<br /> ENVIRONMENTAL HEALTH DEPARTMENT
<br /> 304 E WEBER AVE,3R°FLOOR
<br /> STOCKTON,CA 95202
<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 REPAIRIRETROFIT 'UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT
<br /> 1 EPA SITE # ; PROJECT CONTACT & TELEPHONE # -- -
<br /> +------- -----------------------------------(------------------------'-,- -------�Q�? 7/l;
<br /> F 1 FACILITY NAME ��f PHONE-#
<br /> I CI1 . ADDRESS - --- "��1--1`��' �\�--- 4=v YJ
<br /> L CROSS STREET-------------------- —av
<br /> I I + -------------------------------------------------------------
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<br /> Y , OWNER/OPERATOR ---_U (�( ; PHONE #
<br /> L ,
<br /> --+-------------------- -----------------------------------------------------------+--------- - ----------
<br /> C CONTRACTOR NAMEr , ..r�T✓3�'�y`� �j�C'K�n-C) - - ------------ PHONE_#_ ---
<br /> 0 +------------------- 1 C 1 --------- -_1 --�-iii --
<br /> N ; CONTRACTOR ADDRESS CA LIC # ) ; CLASS 1 lD�
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<br /> R ' INSURERWORK.COMP.# 7
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<br /> C.; -OTHER INFORMATION
<br /> 0 ; I PHONE #
<br /> ' R +------------------------------------------------------------------------------------+----------------------------------------�
<br /> PHONE #
<br /> ----------------------------------------------------------------------------------------------
<br /> 'TANK 2D # r - TANK SIZE ; CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED
<br /> 39-
<br /> T ; 39-
<br /> A ; 39-
<br /> N ; 39-
<br /> K i 39-
<br /> 39-
<br /> 39-
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<br /> L ; /APPPPRROVED APPROVED WITH CONDI IONS) DISAPPROVED
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<br /> N ME
<br /> N ; PLAN REVIEWERS NAi DATE
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<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."
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<br /> i L.Giti a A1,
<br /> APPLICANT'S SIGNATURE: ( "`" / TITIN Ah, 1.C0 Lc-- DATE
<br /> ,
<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 /> �1- ' 643
<br /> Name �'.r�)�'L (��Yf�-� Address 6<0 b57_n,r, Ftvt,- S� Phone #-f >k-S
<br /> Signature 4� �A �,✓ `vim
<br /> EH230038
<br /> (revised 1/31/02)
<br /> 1
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