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• • SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 3"0 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: + 1 +-LTANK RETROFIT —PIPING REPAIR/RETROFIT_UNDER DISPENSER CONTAINMENT RM E�PA®IR RET-R- -O FI3T- ---- - -------------------------------EPASITE#---- ----------------------- -PROJECT CONTACT b TELEPHONE #--------`---------------------- -S---"------O--QO-- ----+ ---------------------------------------------------------------------------M° ` P_ 0 3I g F FACILITY NAME - ---- ---'------V0.C14_—WCEU -PHONEA-------------------- ---------------------------- C --------------- I ------------------------------ C ADDRESS -------------------------------------------- --------------------------- -------------- 1 - _- ---- --_I -73. L � CROSS STREET � � '� -----------------------------' 6� T -'--'---'--------'-----------------------------------------'--- OWNER/OPERATOR ,_ ------ 1 . 1 O �.1 I PHONE # Y IJP U l lroGc. ---+--------------------------------------------------------- 3 Co - & t(Q - ao 7 1 C I CONTRACTOR NAME ----'-_----'--'-----------+---------- S 2V �i�C SCCO1.1 5� e�jyS=�4C I _ PHONE # _ D +------------------ ------ ----- -------------' `b --3-b03 ------- N ; CONTRACTOR ADDRESS (� /?� ,a, ' //'' [� ` p p I T +---------- �--4=V�K-%.1eF��I.R QS�Ca;-CA LIC # 't'f' J SI O C"' I CLASS -------------- y �! R INSURER A ;----------NOV - RiVt_V 1 �S �c� I WORK. COMP.#oIQI Ob�O ' C OTHER INFORMATION --------------------+-------- ' O I R +---------------------- --------------- I PHONE # i ' II'I PHONE # +---I .............. _ _ _ _ TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- T ; 39- A 39- N 39- I K 39- 39- 39- .............. 9- j 39- 39- +--- 1 L I AP OVEDX:i APPROVED WITH CONDITIONIS) DISAPPROVED ��!///'' ' A ATTACHMENT WITH CONDITIONS)DAT l/ - it N PLAN REVIEWERS NAME ✓ _/ (J APPLICANT MUST PERFORMALL ORK IN ACCORDANCE TH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS F SAN JOAQUIN COUNTY, ENVIRO ENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CEROTIFY 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 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,'I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: I��Gt ( L(�- y r%t L titi(� /�� II� f,`��-��C IN i, iG./ 3 tI TITLE _ab �F ` vCiA" DATE ` +---------------------------- ' 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. NametAACVW V, U 1`Q9AeJ Address &jakw due.,5�, thr 9 Phone # 4OR-- oZl3- (ob3g Signature l u CA-�Cii. EH230038 (revised 1/31/02)