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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3R0 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/RETROFITUNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />+----------------------- ------------------------------------ <br />EPA SITE # -_-PROJECT-CONTACT-i TELEPHONE -# U ,y �,r�y�, ,,e ,_, ,n <br />--------------- <br />F <br />� 06 ) , 1_ <br />+-----SI ----- t------------- 4 r; HjT, VW+�'4 ALV �l.Y`(Q <br />F ) FACILITY NAME <br />rl� `l�•l._ N ------------------------------------------------ <br />C- - - - -- - <br />I A +----------------- + !� ) PHONE #---- <br />-�1 r� tom' � ( 'T�-n ��rW�I `` ,1 --- <br />I ADDRESS _ f A - N --_l_` v�__�f_-ewd, _1-_rV6LC Q& ----T-S73-71P <br />I+-------------, <br />, <br />L CROSS STREET Is- - - <br />T OWNER/OPERATOR <br />Y lPHONE # <br />0� k0.l-&ar <br />11 <br />-- -------- °C � J� �� <br />.: . ). CCONTRACTOR- NAME Q�G. __ ' r * .. ---O- - . <br />PHONE"# <br />----------------------- Fo� - t3� <br />N ; CONTRACTOR ADDRESS `� c' <br />- --------------- <br />I T +--------------- G� O J C:AY LIC # CLASS <br />e <br />------------- 4------------- <br />---------------- - ------'--------- At. C'( 1 <br />R INSURER�� ___----_ <br />WORK.COMP.k� A�3 j be -A1 <br />A :Rfo <br />C OTHER INFORMATION ��-------- <br />, <br />R +--------------------- PHONE # <br />PHONE # <br />-----------------------------------------------------,------------- <br />---------------------------I <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED <br />39- <br />T 39- <br />A 39- <br />N 39- <br />I K ; 39- <br />39- <br />39- <br />L I PRO D APPROVED WITH CONDITION(S) DISAPPROVED �. <br />A TimS ACHMENT WITH CONDITIONS) /� <br />N PLAN REVIEWERS NAME F''1 <br />+---) � DATE„ <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WI SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAOUIN 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 I•SSUEDi• I,SMALL NOT EMPLOY ANY'PERSQN IN:,SUCH .A.MANNEB AS .TO .', <br />BECOME SUBJECT TO WOAKEk'S. COMpEN$A1'#ON LAW$.OI`.CALIFORNIA'.'" ..CONTRACTOIL'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 PERSONSSUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />' APPLICANT'S SIGNATURE: {'l.'l ""v�--'4t''�'� ' '�'i�-G(--fiw-,p-�I,.l�.: TITLE (J_muzk k AL 6W"/DATE 7 J.! 0 : <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 RWM4 V• WECMRAN Address (A0 Ci�^�ucc Au.e, ,S� ( QSI(ol— Phone # 407� <br />Signature 1woLLt1ZL <br />T <br />EH230038 <br />(revised 1/31/02) <br />1 <br />