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r� <br />n <br />SAN'JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH <br />304 E WEBER AVE, 3"D 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 REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />+--------------------- --------------------- _ <br />1 EPA SITE # 1 PROJECT CONTACT 6 TELEPHONE # <br />+---------------------------------------------------------------------------- --- --- --- - ,a--------- - `f0iS' QP(3 <br />1 F 1 FACILITY NAME "� Cf `�, g ------------------, <br />1 A +--------------------'--'_------- �_l_l,l -__ PHONE # <br />' C 1 ADDRESS - <br />1 1 +---------------- 1------'t- <br />L ) CROSS STREET y —' '---------'----'-------------' <br />I+-------------------------------------------------------- <br />1 T 1 OWNER/OPERATOR �` p� ! --------"___________________________________________________________1 <br />Y 1 J °C�. lam' C- l U -CZ C. PHONE q <br />---+--'------------------------------------------------------------- i <br />c--------------------+---------------------------------------i <br />1 C 1 CONTRACTOR NAME J��t -- G - �a <br />1 O : CONTRACT-- -_-"" ------ ti-- �-� S-`.�...4(�.L- PHONE -#--- -- - � ® 6 <br />1 N 1 CONTRACTOR ADDRESS (''� - ---- ------'-�----'---' <br />1 T +-------------------- L---- Ut�/A--- �F-----� - SL 1 CA LIC # ' S S-1 1 CLASS <br />R I INSURER q - - ------ ------- - --- <br />t/� � j C Int `b 4 <br />A 1 ---------- "'_C ---- .L USS �� I WORK. COMP.# � 6 y <br />--------------- --- `��� J- t <br />{ C 1 OTHER INFORMATION - ----- <br />0 , <br />1 R +--------" ---------'-- 1 PHONE # <br />r i <br />------------------+--------------------------------- <br />+---111.11•• " ••11111)11111,...... :_PHONE # <br />TANK ID # TANK SIZE ) CHEMICALS 34 - <br />STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />T 39- <br />1 A ; 39- <br />1 N ; 39- <br />K 39- <br />39- <br />39- <br />L AP OVED APPROVED WITH CONDITION(S) DISAPPROVED ATTACHMENT WITH CONDITIONS) <br />1 A 1 L ( E <br />zSN PLAN REVIEWERS NAME °( <br />T. <br />DATEiiiriiiiiiiiiiiririiiri <br />APPLICANT MUST PERFORM ALL ORK IN ACCORDANCE TH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY, ENVIROV 4ENTAL 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 />P i Q <br />APPLICANT'S SIGNATURE: 1 , 4 a o(, TITLE <br />e DATE <br />+------------------------------------------ <br />IN01 t 0 <br />Indicate the responsible party to be billed for additional EHID 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 />• - �.. ; <br />EH230038 <br />(revised 1/31/02) <br />